J Support Oncol. 2012 Jul 16. [Epub ahead of print]

Twelve Reasons for Considering Buprenorphine as a Frontline Analgesic in the Management of Pain.

Davis MP.

PMID: 22809652

When I am trying to convince patients to switch from their current opiate for chronic pain (which they have usually lost control of, considering that I have these conversations at the Addiction Recovery Service) to buprenorphine and review the advantages, they often ask why didn't their doctor start them buprenorphine instead of morphine, hydrocodone, oxycodone etc. 

This article encourages physicians to consider buprenorphine, specifically the transdermal patch, as a first line agent in the approach to chronic pain.  I have some misgivings about opiate management of chronic pain in any case and find the data that exists fairly unconvincing given the potential for opiate induced hyperalgesia.  However I do concur with this author on the advantages of buprenorphine compared to the full mu agonists that are usually prescribed.

The twelve reasons given are

(1) Buprenorphine is effective in cancer pain(2) buprenorphine is effective in treating neuropathic pain(3) buprenorphine treats a broader array of pain phenotypes than do certain potent mu agonists, is associated with less analgesic tolerance, and can be combined with other mu agonists(4) buprenorphine produces less constipation than do certain other potent mu agonists, and does not adversely affect the sphincter of Oddi(5) buprenorphine has a ceiling effect on respiratory depression but not analgesia(6) buprenorphine causes less cognitive impairment than do certain other opioids(7) buprenorphine is not immunosuppressive like morphine and fentanyl(8) buprenorphine does not adversely affect the hypothalamic-pituitary-adrenal axis or cause hypogonadism(9) buprenorphine does not significantly prolong the QTc interval, and is associated with less sudden death than is methadone(10) buprenorphine is a safe and effective analgesic for the elderly(11) buprenorphine is one of the safest opioids to use in patients in renal failure and those on dialysis(12) withdrawal symptoms are milder and drug dependence is less with buprenorphine

I strongly recommend to read the entire article 

Another recent publication compared 0.4 mg SL buprenorphine favorable to 5 mg IV morphine for ER management of acute fracture.

Ann Emerg Med. 2012 Apr;59(4):276-80. Epub 2011 Nov 23.

Sublingual buprenorphine in acute pain management: a double-blind randomized clinical trial.

Jalili M, Fathi M, Moradi-Lakeh M, Zehtabchi S.

Buprenorphine management of both acute and chronic pain will certainly have risks, but it is encouraging to see it's advantages to full opiate agonists being published.