The global “opioid crisis” has placed enormous
pressure
on the opioid ligand discovery community to produce novel opioid analgesics
with superior opioid-related adverse-effect profiles compared with
morphine. In this Perspective, the multitargeted opioid ligand strategy
for the discovery of opioid analgesics with superior preclinical therapeutic
indices relative to morphine is reviewed and discussed. Dual-targeted
μ-opioid (MOP)/δ-opioid (DOP) ligands in which the in vitro DOP antagonist potency at least equals that of
the MOP agonist activity, and are devoid of DOP or κ-opioid
(KOP) agonist activity, are sufficiently promising candidates to warrant
further investigation. Dual-targeted MOP/NOP partial agonists have
superior preclinical therapeutic indices to morphine and/or fentanyl
in nonhuman primates and are also considered promising. Based on the
poor preclinical and clinical therapeutic indices of cebranopadol,
which is a full agonist at MOP, DOP, and NOP receptors and a partial
agonist at the KOP receptor, this pharmacologic template should be
avoided.