Pain management

 

The Relief of Suffering: History and Challenges of Pain Management, from the World to Togolese Hospitals

The management of pain has undergone a radical transformation in the history of medicine, shifting from a burden considered ineluctable to an ethical and clinical priority. Now recognized as the fifth vital sign, it mobilizes sophisticated strategies in hospital and emergency medicine. This evolution, universal in its principles, reveals complex and contrasting realities depending on geographical contexts, notably between developed healthcare systems and the specific challenges encountered in Sub-Saharan Africa, particularly in Togo.

I. The Historical Evolution of Pain Management Worldwide

The history of pain management is marked by struggles against philosophical and religious dogmas. For centuries, the relief of suffering was not the primary goal of the physician.

From Antiquity to the Enlightenment: Pain and FatalismJusqiame

Since Antiquity, there is evidence of the use of narcotic agents such as opium or henbane to alleviate ailments. However, the approach was largely empirical. In the Middle Ages and up to the Classical era, pain was often interpreted as a divine ordeal or a phenomenon necessary for healing (the surgeon's dolor). Figures like Celsus, in the 2nd century, encouraged the surgeon to "remain deaf to the cries of his patient" to better concentrate on the technical act. The effort to provide relief was there, but it was hindered by an ethic that valued stoicism and a limited pharmacopoeia.

The Medical Revolutions of the 19th Century

The 19th century marked a double revolution that changed the situation, even if the consequences were not immediate for the treatment of post-operative and chronic pain.

The Opioid Era : In 1803, the discovery and isolation of morphine from opium by Sertürner provided an analgesic tool of unmatched potency. Although rapidly used, notably during the Civil War, this massive use created the first problems of drug dependence, generating suspicion and excessive regulation that would impede its legitimate therapeutic use for over a century.

The Anesthesia Era : The first successful ether anesthesia, by Morton in 1846, freed the surgeon from the constraint of the patient's time and movement. Paradoxically, this revolution focused on abolishing pain during the operative act, often neglecting continuous relief after the operation.

Contemporary Awareness

It was only in the second half of the 20th century that pain was recognized as a disease in its own right.

  • 1973: The Birth of a Discipline :
    • The creation of the International Association for the Study of Pain (IASP) marked the institutionalization of pain. It defined it no longer as a symptom, but as an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
  • The 1990s and 2000s : The Right Not to Suffer :
    • Driven by the palliative care movement and American campaigns promoting pain as the "fifth vital sign" (to be systematically assessed), the fight became a political priority. In France, the law of March 4, 2002, explicitly enshrined the right of every person to receive care aimed at relieving their pain, transforming the ethical obligation into a legal obligation for caregivers and institutions.

II. Pain Management in Hospital and Emergency Medicine

Today, pain management is organized around two main pillars : systematic assessment and the multimodal (or multidisciplinary) approach.

Pain in Hospital Medicine: Chronicity and Palliative Care

In the hospital setting, particularly in oncology, surgery, and geriatrics departments, the challenge is the management of chronic pain and pain at the end of life.

  • Adapted Assessment : The first action is always assessment, using standardized tools such as the Numerical Rating Scale (NRS) or the Visual Analog Scale (VAS) for communicating patients, or behavioral tools (like Doloplus) for non-communicating patients (the elderly, infants, or patients in intensive care).
  • The Multimodal Approach : Treatment is no longer only pharmacological. It follows the WHO's three steps (Paracetamol and NSAIDs, Weak Opioids, Strong Opioids), but is reinforced by:
    • Locoregional Techniques (nerve blocks, epidurals) to target post-operative pain.
    • Non-pharmacological Therapies (hypnosis, TENS - Transcutaneous Electrical Nerve Stimulation, physical therapy, psychotherapy) essential for chronic pain.
  • Fighting Pain Induced by Care (PIC) : Hospitals implement protocols to prevent Pain Induced by Care (PIC) (dressings, punctures) through the systematic use of analgesics or light sedation before the procedure.

Pain in Emergency Medicine: Speed and Safety

In emergency departments or intensive care units, analgesia is a therapeutic emergency.

  • Early Analgesia : Modern recommendations require that pain treatment begins immediately (or within minutes of assessment), without waiting for imaging results or a complete diagnosis. Severe pain is treated as an absolute priority.
  • The Use of Opioids : Morphine and fentanyl are the drugs of choice for severe acute pain (trauma, fractures, renal colic, etc.). Emergency teams are trained to administer these substances safely, often via the intravenous route for rapid action.
  • Procedural Analgesia : For painful procedures (reduction of dislocation, complex suturing), procedural sedation and analgesia are used, employing agents like ketamine or propofol to guarantee the absence of pain and anxiety during the procedure.

III. History and Challenges of Pain Management in Togo

The evolution in Togo is part of a specific socio-historical and economic context, where pain is often insufficiently treated despite the dedication of healthcare staff.

A Complex Historical and Cultural Context

The Togolese healthcare system was structured during the colonial period around dispensaries and the first hospitals (such as the "Reine Charlotte" hospital in Lomé in 1909), prioritizing the fight against major infectious endemics and basic curative care.

  • The Myth of Resilience : Culturally, in Togo as elsewhere, pain is often perceived as a sign of strength of spirit or resilience, particularly in men. Complaining can be minimized by the entourage and, at times, by caregivers. This perception delays the request for help and the administration of treatments.
  • The Scarcity of Palliative Care : For a long time, the concept of Palliative Care, which is the main vector of the anti-pain culture, remained embryonic or confined to isolated initiatives, delaying the integration of robust protocols, particularly for patients with cancer or advanced HIV.

Structural and Pharmaceutical Challenges

The major difficulty in Togo lies in logistical constraints and access to essential medicines, especially opioids.

  • Limited Access to Opioids (Step III) : One of the most critical barriers is access to morphine and other Step III analgesics. Very strict national regulations, recurring stock-out problems, and sometimes a prohibitive cost (without generalized health insurance) prevent their availability, even in the Lomé and Kara university hospital centers, for severe post-operative, traumatic, or cancer pain. The fear of dependence among doctors and pharmacists remains a powerful brake on prescription.
  • Incomplete Assessment : Studies conducted in Togolese hospital centers have shown that, despite knowledge of assessment tools like the VAS, their systematic use for pain follow-up remains insufficient among a portion of the nursing staff. The nursing role often focuses on supportive relationships and basic physical care, with analgesia being perceived as an exclusively medical role, contrary to the modern culture of care.

Signs of Positive Evolution and the Future

Despite these obstacles, pain management in Togo is progressing, primarily driven by training and infrastructure improvement.

  • Training as a Driver : Local and international initiatives focus on training healthcare professionals to :
    • Normalize pain assessment as a systematic action.
    • Overcome prejudices and fears concerning the appropriate use of opioids.
    • Develop skills in Anesthesia-Resuscitation for the management of acute and complex chronic pain.
  • Strengthening Emergency Services: Recent investment in the rehabilitation and equipping of university hospital emergency services (such as at the Sylvanus Olympio University Hospital) has an indirect positive impact. Better-equipped and better-structured services are more capable of applying rapid and effective analgesia protocols for trauma patients or those in acute distress.
  • Integration of the Palliative Care Concept : The gradual recognition of the need for palliative care helps to bring about acceptance of the necessity of relieving chronic and refractory pain, paving the way for better integration of morphine into the care pathway.

In conclusion, if pain management is an acquired right in Western medicine, it remains a major challenge in Togo, where the urgency is to combine ethical will with logistical reality. The future of Togolese analgesia rests on securing the supply chain for opioids and the generalization of the culture of assessment at all levels of care, thus ensuring respect for patient dignity in the face of suffering.