Pain Pioneers

Thirty years ago, an Arkansas anesthesiologist and a Brazilian neurologist opened the Mid-South's first accredited pain clinic.



photography by Larry Kuzniewski

Dr. Kit Mays holds a small framed photograph of a woman perched atop a camel, with pyramids in the background. “This woman had a terrible problem and even had trouble getting around,” he says. “But she got well enough to go to Egypt.” The patient had scribbled on the photo, “Rode on airplane 12 hours (no pain). Never knew that riding a camel was on my bucket list, and all because you hit the spot.” He laughs at the signature — “your old pain in the tail” — and says, “It’s very gratifying to see patients, maybe just one time, and years later have them tell you they got better and stayed better. That is very rewarding.”

Thirty years ago, Mays and Dr. Moacir Schnapp founded Mays & Schnapp Pain Clinic, the oldest pain-management facility in Memphis and at the time the only one between St. Louis and New Orleans. Sitting in the breakroom of their spacious facility just east of Baptist Hospital, they laugh at how well a “sophisticated fellow who speaks at least 11 languages” and “just an ordinary guy from Arkansas, not sophisticated in any way” (as Mays describes himself) teamed up.

The story actually began with a tragedy. Mays lost both his parents while in high school in Arkansas. “They died hard,” he says, “and it was very difficult.” Both parents succumbed to cancer. His mother was allergic to aspirin, and his father had problems, such as addiction and serious withdrawal symptoms, with his pain medications.

“So I saw all sides of their treatment,” he says, and when he entered UT medical school to study anesthesiology, he already had an interest in pain management.

“At that point, pain management was the exclusive domain of the anesthesiologist,” he explains, since physicians in that specialty had the most experience with drugs, opiates, nerve blocks, and other techniques for reducing pain for surgeries and other procedures. After Mays graduated, he considered a residency at Harvard and the National Institutes of Health, but his dean persuaded him to start something new — a multidisciplinary pain clinic at Baptist Memorial Hospital. The new facility — only the third pain clinic in the country — opened in 1976 at the old Lamar Unit. It incorporated specialists in anesthesiology, neurology, psychiatry, and clinical psychology.

This is where Schnapp comes in. “My story is a bit different,” he says. Trained as a neurologist in his native Brazil, he was accepted as the first Fellow of the Baptist Pain Clinic. That was in 1979; a few years later, he was named director of the clinic when Mays left to start a private practice, Anesthesia and Analgesic Associates, located in the Medical Center. He stayed in touch with Mays, though, and in 1983 they teamed up. The Mays & Schnapp Pain Clinic was born, moving into new offices on Humphreys Boulevard.

“We had the space here that allowed us to build it from scratch,” says Schnapp, “so everything was integrated — the physicians quarters, operating rooms, physical therapy.” The partnership became a medical team; Schnapp considers the duo “almost like Siamese twins. We have different specialties, different interests, and different personalities, but we work as a single head in this place.”

Mays explains that “the real advantage is that we miss very little. It’s very reassuring to go into the next room and say, ‘Hey, do you have a minute?’ to discuss a patient, and we do that every day.” Another aspect of the practice that is a bit unusual is the staff. “We haven’t gone the route of using nurse practioners to do a lot of the work, and then we come in and finish it off. We actually see every patient.”

 

Pain management is difficult because, after years of medical advances, nobody has yet come up with a device to measure the intensity of pain. Finding the actual source of any pain is hard enough, but trying to eliminate or reduce it is the most challenging aspect of Mays’ and Schnapp’s jobs.

“There’s a little bit of Sherlock Holmes involved in trying to figure it out,” says Schnapp. “The majority of patients who come here have seen, on average, seven other physicians by the time they see us, and we have to discover what they may have missed, and what else can be done.”

Which brings us to the central principal of the practice. Despite the name of their clinic, Mays and Schnapp don’t focus just on pain.

“Pain doesn’t happen in a vacuum,” says Schnapp. “It is just a sensation, like hot or cold, until it reaches the brain, and then it creates suffering. We don’t deal with pain, we deal with suffering.”

That’s complicated, because determining the extent of that suffering can be subjective. Most doctors use a “pain chart” for the patient to indicate, on a scale of 1 to 10, how bad they feel. “That’s very ineffective,” says Schnapp. “It’s like asking somebody how much they love their children. Pain is completely subjective.” What’s more, it varies, depending on other factors. “If you’re hurting and then learn you’ve just won the lottery, that’s one thing. If you’re hurting the same amount, and then lose your house to a tornado, that’s another matter entirely. Your suffering will be much greater. You will feel more pain.”

According to Mays and Schnapp, a patient’s brain actually dictates the level of pain and suffering, and that can be affected by age, environment, culture, genetics, depression, and drug use.

What does all this mean? Simply that pain management requires much more than reducing the source of pain. “Pain meds alone will very seldom solve the problems of patients that come here,” says Schnapp. “By the time they come here, they often have more complicated issues.”

Pain — for example, a herniated disk in your back — can cause sleep problems and even depression. But the resulting depression can cause patients to feel even more miserable, and to feel the pain more than they should, and to feel more suffering.

Lack of exercise can also increase suffering. Scientists have known for years that exercise releases chemicals that actually help block pain. Researchers have recently discovered a protein called Brain Derived Neurotrophic Factor, which Schnapp says “causes nerve cells to sprout and communicate better. This seems to be produced when people exercise more, and we believe it’s the same type of chemical that people take as antidepressants.”

Mays & Schnapp patients benefit from the clinic’s multidisciplinary and “polypharmacogical” approach. Put simply, says Schnapp, “we try to use all the guns we have to subdue patients’ suffering. We use special meds for nerve damage, for pain, and for depression. We use physical and massage therapy to increase their range of motion. We use nerve blocks to break the cycle of pain. We seldom talk about fixing the problem; we talk about reducing their suffering and increasing their function in real life.”

Though certain pain — the kind generated from cancer, for example — can be intense, it can often be treated. The most challenging type of pain comes from nerve pain, the type of pain caused by shingles, trigeminal neuralgia, and other afflictions, where the nerve itself is damaged.

“Nerve pain does something to the brain that mechanical pain does not,” says Schnapp. “You can break your arm and get a cast and that pain will go away. But if you hit your funny bone hard, it’s a different kind of pain. It’s more intense.”

The alarming thing about nerve pain is that it doesn’t always go away. Although the actual mechanism is unknown, your nervous system can actually “learn” to hurt, and the pain can become permanent. Everyone has heard stories of “phantom pain,” when patients can still feel pain and other disturbing sensations in arms and legs that have been amputated. The same effect can occur with any kind of nerve damage. “Your spinal cord will respond with pain,” says Schnapp, “and even if you clip, or cut, the nerve, you won’t get relief.”


 

Schnapp pauses when asked about the future of pain management — any new techniques or new prodecures? “It’s hard to say. When I was in medical school, they promised me that by now we’d have a magical pain pill that would stop pain, wouldn’t be addictive, and wouldn’t have any side effects.”

Hearing this, Mays says, “Ha!” and shakes his head. Obviously, no “magic pill” has been developed. Even so, great advances have been made in diagnostic tools such as MRIs and PET scans, pain medications, and physical therapy equipment. (Their clinic offers a special AquaCiser, an underwater treadmill machine that lets patients exercise without putting their full body weight on an affected hip, leg, or foot.)

Doctors’ attitudes have certainly changed. “Thirty years ago, if they couldn’t find a reason for the pain, most doctors would find a psychological cause,” says Schnapp. “Before CT scans and MRIs, it was easy to blame the patient for the pain. A surgeon would say, ‘I’ve done everything right, so you can’t possibly be hurting.’ We know better now.”

And the general attitude towards pain management itself has changed. “In the late 1980s, and even into the 1990s, pain management was something new,” Schnapp says. “When I told people I was a pain specialist, they had no idea what I meant. It was like being a psychiatrist in 1912.”

Mays doesn’t argue with the term “pain pioneers,” saying, “Every physician would do pain, but there was nobody who would handle the difficult cases, and doctors in general don’t like those cases because they can be demanding.”

Even today, though, the role of pain clinics isn’t fully understood, he says. “Some people think that going to a pain specialist is something you do as a last resort, when nothing else works,” Mays says. “That’s really never made sense to me. In the long run, it’s not cheaper, it’s not better, and it just causes you more suffering.”      

 

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