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Changing the Standard

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Surgeon Asif Ilyas ’97 Champions Reforming Opioid Prescription Guidelines 

By Koren Wetmore

Asif

Dr. Asif Ilyas ’97, a hand surgeon with The Rothman Institute in Philadelphia, is working to reduce the number of opioids prescribed after surgery. Photo by Dan Z. Johnson

A disturbing revelation struck Asif Ilyas, M.D. ’97 as he read a recent study about potential addiction among surgical patients. Published in JAMA Surgery, it showed that about 6 percent of those prescribed opioids for post-surgical pain were still taking the pills six months later.

An accomplished surgeon, Ilyas had pursued a medical career because he wanted to help people. Yet the study suggested his profession was contributing to the nation’s opioid crisis.

“Six percent—that’s a remarkable number,” says Ilyas, who specializes in hand, wrist, elbow and orthopaedic trauma surgery at The Rothman Institute in Philadelphia. “It’s what made me look critically at patient opioid consumption for various procedures and sparked my search for ways to safely decrease their use post-operatively.”

Research conducted by Ilyas and his colleagues revealed that patients only take about a third of the up to 90 opioid pills surgeons routinely prescribe. The rest lands in home medicine cabinets where family members might take them simply because they are available.

“Multiply that by the number of surgeries we do individually, then by a community, a city, a state and quickly you get into a huge number of opioids that we are inadvertently distributing into society for potential abuse or diversion,” he says.

TACKLING THE PROBLEM

His findings inspired him to experiment with pre-surgical counseling to educate patients about the issue. At first he spoke directly with them about the pain they might experience after surgery, along with the pros and cons of using opioids to manage it. Later he created a five-minute video, which patients now view instead.

Ilyas also reduced the number of opioid pills he prescribes and encourages patients to use an alternative such as the over-the-counter medication ibuprofen. Occasionally patients ask for more pills, he says, but such requests have been the exception, not the rule.

In a pilot study Ilyas did last year of 40 patients who underwent carpal tunnel release surgery, those who received pre-surgical counseling used two-thirds less opioid medication than their uncounseled peers. “That’s a huge improvement that came from just having a five-minute conversation with patients.”

His next goal is to find effective alternatives to opioids, which, surprisingly, might be found at your local market.

In a blind study finished this year, Ilyas and his colleagues gave patients post-surgical pain medication without revealing whether it was the opioid oxycodone or an alternative such as acetaminophen or ibuprofen. They found only a slight difference—both in pain relief and the number of pills used—between those who took the opioid versus those who took an alternative.

AN UNEXPECTED JOURNEY

Ilyas never envisioned being on the front line of the opioid crisis when he graduated from Wilkes with a degree in biology. His plan was to become an internist until his experience as a medical student at Drexel University College of Medicine introduced him to the intricacies of surgery. He went on to complete his orthopaedic surgical training at Temple University Hospital in Philadelphia, followed by a fellowship in hand, upper extremity and microsurgery at Harvard Medical School.

By 2013, he became a pioneer in wide-awake hand surgery, which uses local anesthesia, lowers patients’ costs, and also happens to reduce the need for post-operative opioids. “The effects of the local anesthetic we use helps to reduce pain after surgery,” he explains. “The patient is also awake during the procedure, so that allows me to talk with them about their next steps, including strategies to manage pain.” Ilyas was featured in a March 2017 New York Times story about the awake surgical technique.

To date he has done more than 2,000 hand surgeries in this manner.

He has also taught surgical techniques abroad and has participated in medical mission trips to countries such as Pakistan, Haiti and India. While abroad, he rarely saw the use of opioids following surgery. Most patients outside the United States receive a drug such as Tylenol for pain relief, he says.

“Only in America do you see the expectation that you need 40 opioid pills post surgery. There’s no basis for that beyond cultural standard,” Ilyas says. “It’s our standard, but not necessarily the right one.”

Moving forward, he hopes to study opioid use in a wide array of surgical procedures to develop prescription guidelines for other medical specialties. As the newly elected president of the Pennsylvania Orthopaedic Society, he also aims to provide evidence-based opioid prescribing strategies for physicians and surgeons throughout the state.

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