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This is Carly Beam with the Becker Spine
and Orthopedics podcast. And today, I'm thrilled to
be joined by doctor Asif Elias at Rothman
Orthopedics.
Doctor Elias, thank you so much for being
here today. It's an absolute pleasure to join
you. Thank you so much. Now before we
dive into our questions, can we
hear a little bit from you about your
work and your background?
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 discussing today, I'm
all I also serve as the president of
the Rothman Opioid Foundation,
which I look forward to talking about with
you in greater detail.
Yeah. Absolutely. And, you know, I I heard
on Rothman, you guys,
renewed your partnership with Drexel and their athletic
groups. So I wanna congratulate
you and the team on that. But, as
Indeed. Indeed.
Yeah. As for the Rothman Opioid Foundation, can
you talk about kind of top priorities that
you have going into the 2025,
and how's that kind of align with the
broader mission of what you do?
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 five
zero one c three nonprofit
foundation. So although
it is
born out of,
and staffed by many folks involved with Rothman
Orthopaedics, including myself, it is a separate
nonprofit entity. And we started this entity,
I wanna 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 management research, and we felt
that we need to really dedicate
time and resources
to 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
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 or 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 to,
looking at various legislation, if you will, and
and examples that are many that I can
I 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 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.
And can you talk about some of the
legislative work that you've done specifically for,
opioids bearing?
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 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 eprescribing,
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 getting them, you
would 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 kinda more
consistent with our modern,
style of living,
but also it
it eliminated manipulating
a prescription. It allowed
doctors to prescribe at a more,
and limited number recognizing
that it's easier and better to it's it's
better to refill than to, you know, write
too much and 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 had
championed that has has come forth. And you
would think all states have this, but you'd
be surprised to hear that many states don't.
And 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 wanna 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 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 makes it,
which informs the their physician, but also causes
the the public to be much more,
cautious with,
of opioids.
Got it. And can 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?
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 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 of opioids and pain management in
general. So trying to help
stand 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 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,
you know, 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 a patient's pain, you can manage your
pain very effectively
without relying
on on opioids, which in contrast to say
ten, fifteen, twenty 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.
I like that. Then that idea of stewardship
and really just like a risk based strategic
approach you're taking with pain management.
Yeah. It's recognizing the responsibility
that we have as
with opioids,
and and recognize the risk to,
the
our our patient, but also our public. And
one of the issues that 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,
opioids, and you don't use them, it's now
in your home, and it's a 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 had to
be very careful
in our prescribing of them. That's where that
concept
of, diversion and and stewardship lends itself from.
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 just the different
areas of orthopedic care from hand surgery,
spine, joints?
Indeed.
As you mentioned,
my subspecialty of orthopedics is hand surgery as
well as orthopedic trauma surgery. But, one of
my passions from both a research and a
policy perspective is pain management and orthopedics in
general
and in surgery in general. So there's a
there's a number of 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 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 there's
pain that generated from that. So that's from
the the local tissue trauma or manipulation that
that sensitize the the tissue in that
region,
that pain
perception that has to be carried through the
nerves
to through different points along the the nervous
system, and then 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, m u, the mu
receptor. But we can affect it in 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
proceed whatsoever.
We can write for medications such as NSAIDs
that,
decrease the inflammation in the site of an
area, which also decrease
the decrease the the development of pain. We
can prescribe medications such as gabapentinoids,
commonly 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, they 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 but on a consistent basis. So that
means,
you apply a local anesthetic in the surgical
side. You give every patient a combination of
a Tylenol
as if they can tolerate it and a
gabapentinoid
if they And that's your first line agents,
and those are safe and non nondependency
causing, and it doesn't make you drowsy or
affect your your your clarity of mind. And
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 health care 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 health care provider,
deliberately and specifically
provide some pain management education or counseling before
surgery, patients, do a much better job of
managing their pain and 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 how what you can take
before you need opioids, and if you do
take opioids, how to take them safely to
avoid any other problems associated with them. That's
just two examples using multimodal pain management strategies
and using preoperative counseling is two big innovations
that we've come across that, that have really
changed the way that we manage our patient's
pain.
Those both sound great.
And, you know, my last question, when you
think about this what broader health care trends
have you been
tracking, especially in pain management techniques?
Well, so we've touched on a couple of
them.
One one of the things I I I'll
comment on is that
broadly, we are seeing
much more
awareness
by both the public and prescribers
of the 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 provide direction direction for for 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 in
in pop culture in terms of shows and
movies that have really started to focus on
the the dangers of opioid abuse and addiction.
So that's a that's a very positive trend
that we're seeing,
and we we hope to continue to contribute
to that. But the one trend that's very
concerning, though,
is that we're
a meaningful decrease in opioid related overdose deaths.
Now I'm gonna preface that by saying that
2024
was the 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 a hundred people are dying from opioid
deaths every single day across The US, and
opioid related deaths
are the leading cause of death of 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, it's
not a big drop, a slight drop from
the year before, it's the numbers are still
extremely
high.
Now we hopefully, this 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 by prescribers,
we're not seeing a strong decrease. And one
of the 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,
and the fentanyl market beyond opioid related deaths.
We're also seeing
increasing,
adulteration
of
fentanyl with a substance called Xylazine,
which is
a 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 or, that are forming on people's
limbs who are injecting these
drugs. And these these, wounds can be quite
aggressive,
cutting through, melting away skin, muscle, tendon, and
down to bone, even cause even requiring amputations.
Last year, the Roth and Opioid 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,
of a working group because
Philadelphia has the highest concentration
of these, of this type of drug, xylazine,
adulterated,
fentanyl.
So we create a working group and create
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 opulated deaths nationally.
Oh, doctor Elias, 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. Thank you, Carly,
so much for having me and giving me
the opportunity to talk about the Ralph and
Opioid Foundation and the work that we're doing.
At athena Health, we know your ambulatory practice
wants healthier,
a healthier business, healthier care teams, and healthier
patients.
But the complexities of modern health care 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
lines.
Practicing medicine is complex, but running a practice
can be that much simpler with athenahealth.
See how simpler is healthier at athenahealth.com.