While evidence directly comparing transdermal preparation of buprenorphine with fentanyl is available, that concerning the use of sublingual buprenorphine for acute exacerbation of pain settings is limited to opinion pieces.

Sublingual buprenorphine might not meet the essential pharmacokinetic criteria relevant to use in this setting.

a)Breakthrough pain peaks before SL buprenorphine reaches therapeutic concentrations within the CNS (conflicting temporal profile).

b)Possible interference with the opioid being used for baseline pain control – long half-life with delayed peak effect and high receptor affinity are potential concerns.

While the use of Transdermal Buprenorphine might be suited to use in the frail, renal failure and opioid rotation for baseline pain, positioning of sublingual buprenorphine as an effective agent in breakthrough pain is lacking in basis as well as evidence.

References

Heel, R. C., Brogden, R. N., Speight, T. M., & Avery, G. S. (1979).
Buprenorphine: A review of its pharmacological properties and therapeutic efficacy. Drugs, 17(2), 81–110.
https://doi.org/10.2165/00003495-197917020-00001

Kuhlman, J. J., Lalani, S., Magluilo, J., Levine, B., & Darwin, W. D. (1996).
Human pharmacokinetics of intravenous, sublingual, and buccal buprenorphine. Journal of Analytical Toxicology, 20(6), 369–378.
https://doi.org/10.1093/jat/20.6.369

Schmidt-Hansen, M., Bromham, N., Taubert, M., & Arnold, S. (2015).
Buprenorphine for treating cancer pain. Cochrane Database of Systematic Reviews, (3), CD009596.
https://doi.org/10.1002/14651858.CD009596.pub4