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Becker’s Healthcare Podcast
Tackling the Opioid Crisis with Dr. Asif Ilyas of Rothman Orthopaedic Institute
00:21:06
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- [00:02]
A
@ Athenahealth, we know your ambulatory practice wants healthier a healthier business, healthier care teams, and healthier patients. But the complexities of modern healthcare tech make it hard for you and your care teams to focus on what matters most. That's where athenahealth can help our AI native all in one solutions reduce administrative burdens, streamline billing and payments, and deliver critical insights when clinicians need it most. That means fewer clicks, more time for patients, and stronger bottom Practicing medicine is complex, but running a practice can be that much simpler with Athenahealth. See how simpler is healthier@athenahealth.com.
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B
This is Carly Beam with the Becker Spine and Orthopedics podcast, and today I'm thrilled to be joined by Dr. Asif Ilyas at Rothman Orthopaedics. Dr. Ilyas, thank you so much for being here today.
- [00:55]
C
It's an absolute pleasure to join you. Thank you so much.
- [00:58]
B
Now, before we dive into our questions, can we hear a little bit from you about your work and your background?
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C
Of course. My specialty is as a physician, is an orthopedic surgeon, and specifically I specialize in hand surgery and orthopedic trauma surgery. I'm also a professor of orthopedic surgery at the Drexel University College of Medicine and Thomas Jefferson University, and I'm also an associate dean for clinical research at the Drexel University College of Medicine. But relative to what we're doing discussing today, I also serve as the president of the Rothman Opioid foundation, which I look forward to talking about with you in greater detail.
- [01:42]
B
Yeah, absolutely. And I heard Rothman, you guys renewed your partnership with Drexel and their athletic groups. So I want to congratulate you and the team on that. But indeed, yeah. As for the Rothman Opioid foundation, can you talk about kind of top priorities that you have going into the second half of 2025, and how does that kind of align with the broader mission of what you do?
- [02:10]
C
Of course. Just I'll say first a couple words about the foundation. So, first of all, the foundation officially is called the Rothman Institute foundation for Opioid Research and Education. That's a mouthful. So we call it the Rothman Opioid foundation for short. It's a 501c3 nonprofit foundation. So although it is born out and staffed by many folks involved with Rothman Orthopaedics, including myself, it is a separate nonprofit entity. We started this entity, I want to say, almost six, seven years ago, at least at this point, if not more where we recognize the need around the opioid crisis locally in the greater Philadelphia area and then broader nationally. And at that point we were also doing we're already doing a good amount of work around opioid sparing pain research. And we felt that we need to really dedicate time and resources to redouble our efforts and really focus our efforts around this because we wanted to make a meaningful difference recognizing the edge associated with opioid abuse addiction that we were seeing. So we established this nonprofit foundation. And the mission of the foundation is threefold. One is to educate patients and prescribers on safe opioid use and prescribing, respectively. Two is to perform and or fund research around opioid sparing or alternative pain management strategies. And third is to advocate for evidence based pain management policies. So working with legislators at a local, state and national level to put forward strategies that make sense, essentially serving as a think tank for legislators looking at various legislation, if you will, and examples that are many that I can can talk to you about that we've worked on with legislators. Specific to your question about what we're looking to do at the second half of 2025 is we have a number of ongoing efforts, including education and research and advocacy, as already mentioned as our core mission. One of the things that we're focusing on the second half of this year is on our annual symposium. And we typically hold a symposium at the second half of the year at an important topic. And we bring together different key stakeholders. And we're looking at medical cannabis and we're looking at it from a scientific perspective, a research perspective and a policy perspective. I'm bringing in researchers, bringing in clinicians and bringing in policymakers to discuss this symposium. We're scheduled to have this in early November.
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B
And can you talk about some of the legislative work that you've done specifically for opioid sparing?
- [05:09]
C
Absolutely. So there's a number of things that we've worked on with legislators and I'll focus on our work at the state level. Again, we're based out of Pennsylvania and southeastern Pennsylvania specifically. And some of the really important things that we've done is one, is bring forth e prescribing, electronic prescribing. Understand that several years ago if you wanted to write a prescription for an opioid for a patient, you had to write it in paper on an old fashioned prescription pad. And the problem with that strategy was that one is the prescription could get lost, it could get altered. Two, it was very hard for the patients to get them because they would have to come see you or see someone to get them in hand. And thirdly, you would often, because the difficulty in getting them, you'd often write more than necessary, sometimes because you wanted to make it easier for the patient. E prescribing has created a system that's obviously not only just modern and kind of more consistent with our modern style of living, but also it. It eliminated manipulating of prescription. It allowed doctors to prescribe at a more cost and limited number, recognizing that it's easier and better to. It's better to refill than to, you know, write too much, and then the patient may take more than necessary. And it also allows us to better monitor what patients are consuming. So e prescribing was one of the big things that we champion that has come forth. And you would think all states have this, but you'd be surprised to hear that many states don't. And Pennsylvania is one of those states that was slow to allow for E prescribing. The second big thing that we worked on from a legislative perspective, and there are others, but the big two I want to highlight is the prescription drug monitoring program. And this is basically an online database where anyone who receives a controlled substance that that prescription has to be registered in this database. What that allows is for prescribers to be able to check that database before they prescribe to make sure that the patient is not getting too much or from too many different people. So it allows much more transparency related to opioid prescriptions, which informs the physician, but also causes the public to be much more cautious with solicitation.
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B
Got it. And you talk about some of the biggest challenges that you're seeing when it comes to, you know, effective pain management and specifically opioid sparing approaches.
- [07:48]
C
There are many challenges. Obviously. First and foremost, we want to provide adequate pain control for our patients and for the public for their. For their injuries. And one of the things I always like to emphasize that we, as a foundation and also as a broader practice, we are not anti opioids. We can't do many of the things that we do for our patients and the public in terms of surgeries and managing painful conditions without opioids. The strategy really is how do you manage patients pain with minimizing or mitigating the risk associated with opioids. And opioids have a risk of dependency and abuse that can sometimes spiral into even death of a patient. And that's what we're trying to avoid. So how can you do this in a manner, how can you manage someone's pain in a manner to do this safely. So that's really kind of what we're trying to do. And not to be anti opioids necessarily, but be very cognizant and ultimately be. Well, we like to use the term to be opioid stewards. So stewardship of opioids and pain management in general. So trying to help patients understand that that's what we're trying to do is important. Balancing the challenges of different patient dynamics. You know, patients are all different. They have different conditions, different comorbidities, different site psychiatric dynamics, maybe histories of substance abuse. Those are very challenging problems to manage and then also to create some consistency of care from the physician side as well so that we're not being too erratic or different in terms of how we approach pain. And we do it in a very deliberate and an evidence based manner where again, we're prioritizing good pain control. But what we've learned is when you apply, and I can talk about some of these strategies, when you apply various pain management strategies for, for a patient's pain, you can manage their pain very effectively without relying on opioids, which in Contrast to say 10, 15, 20 years ago, we would use opioids as our first line to manage pain. But now we know that there's a lot of alternative ways to manage pain before we have to go to opioids.
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B
I like that. Then that idea of stewardship and really just like a risk based, strategic approach you're taking with pain management.
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C
Yeah, it's recognizing the responsibility that we have with opioids and recognize the risk to our patients, but also our public. One of the issues that is always central to opioid prescribing is this concept of diversion. What that means is if you're my patient and I give you a prescription for opioids, it's not only that you as the individual may potentially become dependent upon opioids, it's that everyone in your community or in your sphere of influence could potentially have access to those opioids. So if I give you a certain amount of prescriptions, opiates and you don't use them, it's now in your home and it's, it's access to a lot of other people in your sphere of influence. So we, every pill has value for abuse, potentially in sales. So we have to be very careful in our prescribing of them. That's where that concept of diversion and, and stewardship lends itself from.
- [11:14]
B
Got it. And I know you're an expert in hand surgery But I'd love to kind of hear any interesting strategies or research findings that you've found in pain management and reducing opioid reliance across the different areas of orthopedic care from hand surgery, spine joints.
- [11:35]
C
Indeed, as you mentioned, my subspecialty of orthopedics is hand surgery as well as orthopedic trauma surgery. But one of my passions from both the research and a policy perspective is pain management and orthopedics in general and in surgery in general. So there's a number of areas of research and innovation that we have been pursuing, and I'll mention a couple here. One is, and I mentioned this once before, but I'll go in more detail now. One is this concept of multimodal pain management strategies. So what does that mean? That means that there's this concept called the pain pathway, that where you have an injury or surgical or surgery in a certain location, there's pain that generated from that. So that's from the local tissue trauma or manipulation that sensitizes the tissue in that region. That pain perception that has to be carried through the nerves, through different points along the nervous system, and then ultimately it's then perceived in the brain. So there's this pathway, if you will, and there's medications that can affect the pathway at. At various points. When we use opioids, we're affecting pathway in the brain through what's called the mu receptor. Mu. The mu receptor. But we can affect it in lots of different ways. We can affect it by using a local anesthetic in the site of surgery so that there's no pain even perceived whatsoever. We can write for medications such as NSAIDs that decrease the inflammation in the site of an area, which also decreases the development of pain. We can prescribe medications such as gabapentinoids. Common ones are gabapentin or neurontin or pregabalin, also known as Lyrica, that slow conduction and perception of pain. And then obviously we can use analgesics that affect the brain, such as Tylenol and opioids. The thought is if you use these in combination, it can decrease the overall pain experience. And you can then reserve the use of opioids only for strictly backup or for severe breakthrough pain. So one of the things that we've championed is this concept of multimodal pain management where you use a combination of medications that you don't use if you need them, but on a consistent basis. So that means you apply a local anesthetic in the surgical site, you give every patient a combination of a Tylenol as if they can tolerate it, and a gabapentinoid if they need. And that's your first line agents and those are safe and non dependency causing and it doesn't make you drowsy or affect your clarity of mind. And that's often all anybody needs and therefore mitigates even the need or eliminates the need for even opioids altogether. Or if you do need them, you need a much smaller amount. And we've done research in all various specialties of orthopedics, from joint replacements to hand surgery to sports medicine to spine surgery that have shown these have really made a big difference. One of the other areas of innovation that we've really focused on is counseling. As healthcare providers, we routinely speak to our patients and try to educate our patients of various things about their condition and surgery. One of the things that we advocate for is also doing some form of formal opioid pain management counseling or opioid counseling. And we've looked at different ways to do that and to see the effects of them. And we found that when you as a healthcare provider deliberately and specifically provide some pain management education or counseling before surgery, patients do a much better job of managing their pain and can consume much less opioids. One of the things we advocate for is routine preoperative counseling through a, a routine discussion. It could be through information packet or what we recommend is a short video that helps patients understand what pain is, how they can manage their pain, what opioids are, what the risk of opioids are, how, what you can take before you need opioids, and if you do take opioids, how to take them safely to avoid any of the problems associated with that. That's just two examples. Using multimodal pain management strategies and using preoperative counseling is two big innovations that we've come across that have really changed the way that we manage our patients pain.
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B
Those both sound great. And my last question, when you think about what broader healthcare trends have you been tracking, especially in pain management techniques?
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C
Well, so we've touched on a couple of them. One of the things that I'll comment on is that broadly we are seeing much more awareness by both the public and prescribers of the dangers of opioids. And a movement towards opioid sparing pain management strategies is something that we've been advocating for and creating and providing search and direction for some time now. We're starting to see it take foot more and more around not only our region, but nationally. And we're Seeing that in ways related to decreased opioid prescribing and just greater patient awareness. You'll even see it in pop culture in terms of shows and movies that have really started to focus on the dangers of opioid abuse and addiction. That's a very positive trend that we're seeing and we hope to continue to contribute to that. But the one trend that's very concerning though is that we're seeing a meaningful decrease in opioid related overdose deaths. Now, I'm going to preface that by saying that 2024 was first year there was a slight decrease from the year before. Prior to that, almost every year after year there was a steady increase in opioid related deaths in the United States. Over 100 people are dying from opioid deaths every single day across the US and opiate related deaths are the leading cause of death of young adult Americans, surpassing car accidents and gunshot injuries. So it's a big problem. And although we did see a slight drop last year, and it's not a big drop, a slight drop from the year before, the numbers are still extreme, extremely high. And we hopefully that one year down will be a trend. But one year right now is not a trend. It's just one year we will see. But we're concerned by the fact that despite increased awareness, despite strong research, despite greater awareness of the public, despite more conscientious prescribing by prescribers, we're not seeing a strong decrease. And one of the reasons for that is the illicit opioid drug, unfortunately, fentanyl. Illicit fentanyl production and sales continues to be rampant across the country. And more worse than that, we're also seeing some complications related to the illicit fentanyl abuse in the fentanyl market. Beyond opioid related deaths, we're also seeing increasing adulteration of fentanyl with a substance called xylazine, which is a animal or veterinary sedative for large animals. And it's being mixed with fentanyl to increase its effect. But the side effect that we're seeing from mixing of xylazine with fentanyl are these really severe necrotic wounds that are forming on people's limbs who are injecting these drugs. And these wounds can be quite aggressive, cutting through, melting away skin, muscle, tendons and down to bone, even cause, even requiring amputations. Last year the Rothman Opiate foundation held a symposium just dedicated to xylazine associated wounds. We had focused on that. Last year we had the product of that was development of a working group because Philadelphia has the highest concentration of these, of this type of drug, Xylazine adulterated fentanyl. So we created a working group and created a consensus paper on how best to manage these wounds. But in terms of your question about what are some of the trends, we're seeing better awareness and better prescribing, but we're also seeing, we are not seeing a meaningful decrease in opioid deaths nationally.
- [20:07]
B
Oh, Dr. Ilyas, thank you so much for joining us today. It's been a pleasure speaking with you and I look forward to connecting with you down the line.
- [20:14]
C
Thank you, Carly, so much for having me and giving me the opportunity to talk about the Rothman Opioid foundation and the work that we're doing.
- [20:22]
A
At athenahealth. We know your ambulatory practice wants healthier a healthier business, healthier care teams and healthier patients. But the complexities of modern healthcare tech make it hard for you and your care teams to focus on what matters most. That's where Athenah Health can help our AI native all in one solution reduce administrative burdens, streamline billing and payments, and deliver critical insights when clinicians need it most. That means fewer clicks, more time for patients, and stronger bottom lines. Practicing medicine is complex, but running a practice can be that much simpler with athenahealth. See how simpler is healthier at athenahealth. Do.
- [21:06]
C
You.