Alex Cahana

It is my pleasure to nominate Dr. Alex Cahana for the David B. Thorud Leadership Award. Dr. Cahana is Professor of Anesthesiology & Pain Medicine, the Hughes M. and Katherine G. Blake Endowed Professor for Health Psychology, Chief of the Division of Pain Medicine, and Adjunct Professor of Medical History & Ethics, and Adjunct Professor of Radiology. Dr. Cahana epitomizes all of the key qualities important in the David B. Thorud Leadership award.

Dr. Cahana was recruited to the University of Washington Department of Anesthesiology & Pain Medicine in April 2008 to revitalize our interdisciplinary pain medicine program. As you will learn in this letter, he has not only revitalized our pain program but also revolutionized it into a model that has national and international respect. The University of Washington’s founding Department of Anesthesiology & Pain Medicine Chair, Dr. John J. Bonica, is the “founding father” of the discipline of pain medicine and the multidisciplinary approach to pain treatment. Thus, given the birthplace of pain medicine is our department; it is only fitting that we should lead not just the country, but the world, in the field. Due to this goal of international prominence, we recruited Dr. Cahana to revitalize and lead our Division of Pain Medicine which had lost the luster and prestige of its heyday. His work has gone beyond our expectations and exemplifies the characteristics sought in a Thorud Award winner: innovation, teamwork, collaboration, and leadership.

In brief, Dr. Cahana received his medical degree and anesthesiology training in Israel. He trained in acute/chronic pain with leading pain faculty in the U.S. at both Vanderbilt University and the Cleveland Clinic. He started a multidisciplinary pain clinic in Geneva essentially from “scratch.” This clinic grew to 23 practitioners from a cross-section of relevant disciplines/specialties, and is the largest and most efficient pain clinic in all of Switzerland. Dr. Cahana was awarded Purple Heart as a Combat Medical Officer in the Israeli Defense Forces. Clinically speaking, Dr. Cahana is a gifted interventional pain specialist, known for his work in pulsed radiofrequency neuromodulation and interventional pain treatments.

At a local level, Dr. Cahana has revolutionized pain medicine at the University of Washington by recreating the multidisciplinary pain clinic that John Bonica, MD originally started many years ago, but in a modern version. To do this, he has brought together a true collaboration between physical rehabilitation medicine, psychiatry, anesthesiology, neurosurgery, nursing, pharmacy, radiology, oral medicine, general surgery, internal medicine, and neurology. Rather than having pain medicine fellows simply rotate through such disciplines as part of their training, Dr. Cahana has all such individuals working side-by-side as faculty in the same clinic, bringing their unique perspective on pain medicine to bear on the patients seen. Dr. Cahana is expanding the pain fellowship to 2 years so that deeper pain mechanisms can be taught through research training and further clinical rotations of increasing complexity. He has also been instrumental in revamping how the pain medicine is taught at the University of Washington School of Medicine through his support of David Tauben’s role in teaching across classes and disciplines, important principles of pain management. Dr. Cahana himself is appreciated as a strong teacher of medical students as well.

Dr. Cahana represents the type of individual who goes beyond today’s interventional (needle jockey) focus to address some of the truly important questions in pain that should ultimately move the field forward, ultimately enhancing practitioners’ ability to treat patients with pain more effectively. His new clinic is an interesting mixture of non-interventional pain management as well as the latest technology (he has the only 3-D image processors on site so that interventional pain blocks can be performed in 3-D in real time on patients.) He has recruited leaders from the 5 pain societies nationally and internationally, each who sees pain and its treatment in different ways — and these faculty work together effectively as a team.

The Department of Defense (DoD) named our pain clinic as the model for the entire US; this was in spite of the fact that the clinic only officially opened 6 months prior to the DoD’s site visit. Among the clinic’s other awards since Dr Cahana took the helm are, the American Pain Society 2010 Centers of Excellence Award, Joint Commission Best Practice Award, and the World Institute of Pain Excellence in Pain Practice Award for Comprehensive Multidisciplinary Pain Practice for 2011-2015. Dr Cahana recently personally received The Surgeon General Commander’s Medal of Excellence, as well as recognition from the Vice Chief of Staff of the US Army and the Western Region Medical Commander. His leadership is truly unique and is a sentinel accomplishment for Dr. Cahana.

One of the reasons the pain center received so many accolades is that, in 2010, Dr. Cahana put in place a pain outcomes registry, the first of its kind in the country. This registry is essentially a large, sophisticated database that allows clinicians to track and monitor all of the care their patients receive and allows them to study important outcomes such as pain, function and emotional well-being. Each patient completes online questionnaires with validated survey instruments on anxiety, depression, functional activity, mapping of their pain location/intensity/characterization, etc; the pain outcomes scoring is called C-PAIN. This is repeated in a shorter version for each subsequent clinic visit for each patient. This practice allows pain clinicians to evaluate the comparative effectiveness of our treatments and identify best practices that increase the probability of excellent outcomes among our patient. It also allows providers to receive an individual assessment report for each patient so that they can better focus treatment. Thus far the registry contains approximately 10,000 patients and an entire clinical outcomes research group is analyzing the data and is reaching important new discoveries on best practices for optimal outcomes in specific subtypes of pain patients. This analysis group has formed a center called the Center for Pain Research on Impact, Measurement and Effectiveness (C-PRIME) which is directed by Dennis Turk, Ph.D., the Bonica Professor of Anesthesiology & Pain Medicine, a member of Dr. Cahana’s pain group. The key kernel of success in this entire project is that Dr. Cahana has established a platform for integrating metrics/outcomes-based pain medicine therapy into an outpatient clinic setting and in primary care allowing better continuity between primary and tertiary care. If this can be done in one of the most complex and difficult patient scenarios, it in fact is a model for health care reform nationally! Indeed, Dr. Cahana received in November 2011 the Honorary mention of the Association of American Medical Colleges (AAMC) Health Care Innovation Challenge, recognizing the UW model of Pain care as a transformational health care delivery program.

This year the Pain Medicine Division also launched TelePain, a major initiative that allows UW Pain Medicine physicians to offer consultative services to physicians located in remote and underserved areas throughout the WWAMI (Washington Wyoming, Alaska, Montana and Idaho) region. TelePain uses telemedicine technology (technology that combines video conferencing and advanced imaging technology) to address one of the major issues facing chronic pain patients today — a lack of access to pain medicine specialists, which can lead to insufficient pain management and inappropriate opiate use. Dr. Cahana is currently implementing this model of coordinated care management with the SCOAP project to be eventually adopted in Washington State, and to subsequently serve as a model for national healthcare reform in the way primary care and specialty care collaborate.

In addition to leading the clinic as described above, Dr. Cahana is Chief of the Division of Pain Medicine at the University of Washington, effectively integrating pain medicine at the 4 key hospitals – Seattle Children’s, UWMC, Harborview Medical Center, and the Puget Sound VA. He is a leader at the state level in an opioid awareness program and has established a leading pain medicine conference each fall for general practitioners so they can be more effective in managing patients with chronic pain. He has also testified in Washington DC before Congress on pain initiatives and is bringing together the pain community across the U.S. with a single, uniform, pain assessment tool so that (finally) important outcome questions in pain can be addressed with consistent, high volume data. Administration and vision are key strengths for Dr. Cahana.

Another major project Dr Cahana and his colleagues have been working on is working with lawmakers in Washington State and nationally to set better standards for opiate prescription with the goal both to improve the treatment of patients with acute and chronic pain and to reduce the number of opiate overdose-related deaths. As of last year, accidental overdose became the number one cause of accidental death in Washington State, surpassing car accidents for the first time. Fortunately, this year the Washington State Legislature passed a bill on pain management (ESHB 2876), which went into effect on June 30th 2011. Dr Cahana and his team at UW Anesthesiology & Pain Medicine spearheaded the consultation process among state legislators, the State Attorney General’s Office, as well as professional bodies and non-governmental organizations representing healthcare providers and patients to make this law possible. The result of this process was a legislative bill that revolutionizes the approach to pain management, with an aim to reduce the needless amount of overdose-related deaths resulting from excessive prescribing of opioids. A central component of this bill is to mandate a measurement-based approach for patients on high doses of prescription opioids, emphasizing the monitoring of outcomes and enhancing the access to consults with pain specialists.

To address the requirements of this bill, Dr Cahana and his team have designed a novel model of care that emphasizes coordination & collaboration between providers and their patients, and is guided by measurement-based approaches to ultimately enhance the value of healthcare delivery. Our pain assessment and outcomes registry (described above) is being adopted as the measurement-based approach for monitoring patient outcomes and is being expanded throughout the UW Medicine system, across the state, and now there is serious interest in Alaska, Oregon, New Mexico, Ohio, West Virginia, Maine, New York, California and Texas to consider this as a new state paradigm there as well. Dr. Cahana presented his model to the 50 State Attorney Generals at their annual assembly, has been working closely with Director Kirlekowski, head of the Office of National Drug Control (the ‘Drug Czar’) as well as with House and Senate officials in Congress to promote federal legislation.

Dr. Cahana is also spearheading efforts to promote our UW model of care at the national level. The past year saw these efforts come to fruition with a joint collaboration established between UW Medicine, the Department of Defense (DOD) and the Department of Veteran’s Affairs (VA). The Department of Anesthesiology and Pain Medicine has been recognized as a Center of Excellence by the Office of the Army Surgeon General’s Task Force on Pain Management, and has been selected to develop a regional Pain Management Initiative incorporating UW Medicine, Madigan Healthcare System at Joint Base Lewis-McChord, and the Veteran’s Affairs Puget Sound Healthcare System. The goal is to develop a coordinated and collaborative model of care between DOD and VA healthcare systems, in order to reduce pain and suffering among our nation’s soldiers, veterans and their families. Once the regional model is implemented, it is the intention of the DOD and the VA to export the model nationally to foster collaboration and continuity of care among all the DOD and VA healthcare systems across the nation. Efforts to adopt our model within the US Army’s healthcare system is already underway, with the DOD recently awarding a $2.1 million grant for implementing our pain registry at Walter-Reed Army Medical Center and at Madigan Healthcare System at Joint Base Lewis-McChord.

Finally, Dr Cahana continues to emphasize the importance of research as a fundamental guide to our course of action in fostering the paradigm shift in healthcare delivery. As a result, the past year also included an important research milestone for our department, with the founding of the Center for Pain Research on Impact, Measurement and Effectiveness (C-PRIME), briefly described above. Our dedicated research team at C-PRIME is fostering research collaboration not only between our research and clinical personnel at UW Medicine, but is also spearheading research collaborations nationally with the DOD and VA systems. Several of our research projects have been presented at national and international conferences in the field of Pain Medicine, organized by professional bodies such as the American Pain Society, the American Academy of Pain Medicine, the International Association for the Study of Pain, and the World Institute of Pain. Additionally, the team at C-PRIME continually develop grant applications for competitive funding mechanisms through prestigious agencies such as the National Institutes of Health, Agency for Healthcare Research and Quality, and the U.S. Army’s Henry M. Jackson Foundation for the Advancement of Military Medicine.

In summary, Dr. Alex Cahana exemplifies the characteristics sought in a Thorud Award winner: innovation, teamwork, collaboration, and leadership. His leadership has led to an entirely new way of thinking about pain medicine which is a demonstration of a model for health care reform in the U.S. in many clinical settings beyond pain medicine. I hope the committee will agree that Dr. Cahana is well deserving of this award.