Reviews

Opioid receptors: drivers to addiction?

Emmanuel Darcq1 and Brigitte Lina Kieffer   1,2*
Abstract | Drug addiction is a worldwide societal problem and public health burden, and results
from recreational drug use that develops into a complex brain disorder. The opioid system, one of
the first discovered neuropeptide systems in the history of neuroscience, is central to addiction.
Recently , opioid receptors have been propelled back on stage by the rising opioid epidemics,
revolutions in G protein-​coupled receptor research and fascinating developments in basic
neuroscience. This Review discusses rapidly advancing research into the role of opioid receptors
in addiction, and addresses the key questions of whether we can kill pain without addiction using
mu-​opioid-receptor-​targeting opiates, how mu- and kappa-​opioid receptors operate within
the neurocircuitry of addiction and whether we can bridge human and animal opioid research
in the field of drug abuse.

Psychotomimetic
An effect caused by drugs,
mimicking symptoms of
psychosis, such as agitation,
delusions and delirium.
1
Douglas Mental Health
Institute, Department of
Psychiatry, McGill University,
Montreal, Quebec, Canada.
2
Institut de Génétique et de
Biologie Moléculaire et
Cellulaire, INSERM, Centre
National de la Recherche
Scientifique and University of
Strasbourg, Strasbourg,
France.
*e-​mail: brigitte.kieffer@
douglas.mcgill.ca
https://doi.org/10.1038/
s41583-018-0028-x
Opium is extracted from the seeds of poppies (Papaver
somniferum) and has been used for more than 4,000 years
in medicinal and recreational practices to relieve pain
and cause euphoria. Morphine was isolated in 1805 as the
most active component of opium1 and remains the most
potent painkiller in modern medicine, despite severe
adverse effects and a strong potential for addiction.
Heroin, the diacetylated form of morphine, was origi-
nally marketed as the first non-​addictive opiate to treat
cough and asthma in 1898, yet heroin addiction has
represented a major societal problem ever since.
More recently, an ‘opioid epidemic’ has emerged in
occidental countries, particularly in North America2.
The overprescription of opioids for pain relief in the
past 20 years has led to a rapid surge in the non-​medical
use of prescribed opioids, with deaths by overdose and
transition to heroin abuse rising at alarming rates3–6.
The increasing availability of low-​cost synthetic opioids,
such as non-​pharmaceutical fentanyls7, further feeds the
epidemic. This opioid crisis has fostered novel public
policies and much interest in developing better opioids
to treat pain. For medical purposes8, the ideal opiate
drug would relieve pain with high and sustained efficacy
(that is, without tolerance), without the threats of res-
piratory depression (the main cause of overdose) and
without drug dependence (contributing to addiction).
The early 1970s saw the game-​changing discovery
that opiate drugs bind to receptors in the brain (see ref-
erences cited in ref.1) and hijack a complex endogenous
neuromodulatory system. The opioid system comprises
three homologous G protein-​coupled receptors (GPCRs)
known as mu-, delta- and kappa-​opioid receptors
(MORs, DORs and KORs, respectively). Under physio­
logical conditions, opioid receptors are stimulated by
endogenous opioid peptides, forming a peptide family
that includes β-​endorphin, enkephalins and dynorphins.
Distributed throughout the nervous system, opioid pep-
tides and receptors reduce responses to painful stimuli
and stress, and influence reward processing and mood.
The latter influence represents a fundamental role of the
opioid system and will be a main focus of this Review.
Note that the activity of the endogenous opioid system is
extremely broad and covers many other aspects of phys-
iology and behaviour (reviewed in ref.9), but these are
less related to addiction and will not be discussed here.
In the late 1980s and early 1990s, the isolation
of three genes encoding opioid peptide precursors
(namely, POMC, PENK and PDYN, which encode
proopio­melanocortin, preproenkephalin (also known as
proenkephalin) and preprodynorphin (also known
as prodynorphin), respectively) and the genes encoding
MORs (OPRM1), DORs (OPRD1) and KORs (OPRK1)
opened an era of molecular and genetic investigations
of the opioid system10,11. Oprm1 deletion in mice simul-
taneously eliminated the analgesic, rewarding and
dependence-​inducing effects of morphine12, demon-
strating that the MOR is the sole responsible receptor
for both the therapeutic and the adverse actions of
morphine. The MOR is also the key molecular target
for biological effects of other clinically useful and/or
abused opiates (including heroin, fentanyl, oxycodone
and methadone). Given the high risk of adverse effects of
MOR agonists, the enthusiasm for drug discovery efforts
targeting MORs abated in the late 1990s (although new
efforts are starting; see Box 1).
On another front, Oprd1-knockout mice revealed that
DORs have anxiolytic and antidepressant functions13,
decidedly distinguishing this receptor from MORs. Many
pharmacological studies have now implicated DORs in
mood disorders and chronic pain14–16. By contrast, KOR
activation produces both aversive and psychotomimetic
effects17. This peculiar profile has strongly limited the

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Reviews

Box 1 | Can we kill pain without addiction using MOR opiates?

Many drug discovery programmes targeting mu-​opioid receptors (MORs) Other approaches
for analgesia without addiction have had limited success. However, recent Other approaches163 (part c of the figure) include identifying
advances in G protein-​coupled receptor (GPCR) biology have revitalized compounds acting at multiple opioid receptors, opioid receptor dimers
the field. (MOR–delta-opioid receptor (DOR); see Supplementary Box 1) or
opioid–non-opioid receptor dimers (for example, MOR–CC-​chemokine
Biased signalling
receptor 5 (CCR5)); compounds with agonist and antagonist activity at
GPCR conformation depends on biological context. The active complex is
MORs and ‘anti-​opioid’ receptors (such as cholecystokinin, neurokinin 1
determined by the drug and neighbouring proteins, including effectors150.
or the nociceptin peptide receptor), respectively; and compounds
Thus, different agonists may engage distinct effectors, leading to
targeting effectors besides arrestins (for example, regulator of G
biased agonism (see part a of the figure). Biased MOR agonists might
protein signalling (RGS) proteins). In addition, a compound binding a
reduce pain with minimal adverse effects151–153 (part b of the figure). Mice
truncated MOR isoform (lacking the first transmembrane domain) had
lacking β-​arrestin 2 (β-​arr) — one of the two main MOR effectors —
an encouraging pharmacological profile, although with unusual
showed enhanced morphine analgesia154 and reduced morphine-​induced
properties164,165; the biological importance of this isoform remains
constipation and respiratory depression155. Gi-​biased MOR agonists that
unclear166.
minimally recruit β-​arr include TRV130 (also known as oliceridine;
In a novel approach (part c of the figure), the active MOR receptor
identified through cell-​based assays)156, which is in a phase III trial for
structure167 was used to computationally simulate ligand docking at low
analgesia157, mitragynine pseudoindoxyl (developed from natural
pH, with the rationale that binding in an acidic environment might limit
products)158 and PZM21 (identified using computational docking)26. These
effects to injured sites. A pH-​sensitive fluorinated fentanyl derivative
compounds confer strong analgesia with reduced constipation and
called NFEPP reduced inflammatory pain without central or intestinal
respiratory depression in rodents. Novel MOR agonists covering the entire
effects168.
Gi–β-​arr bias range were recently designed, with Gi bias correlating with
Adverse effects might be limited by mimicking or enhancing
the analgesia–respiratory depression therapeutic window159.
endogenous opioid signalling (part d of the figure). Endogenous opioid
Biased signalling in cells has not often been correlated with
analogues with improved stability and bioavailability have been
addiction-related behaviours (for example, drug reward), as these in vivo
developed163. Recently, MOR positive allosteric modulators were
experiments are less amenable to medicinal chemistry efforts. The three
developed to act on allosteric sites (2) to facilitate agonism at the
compounds in part b do not induce conditioned place preference at
orthosteric site (1), strengthening MOR activity at the optimal times
analgesic doses26,158. However, further research should assess the hedonic
and sites, with fewer adverse effects (part d of the figure)169.
and motivational properties of Gi-​biased drugs; a first study has mixed
BMS-986122 enhances opioid peptide-​induced signalling170 and
conclusions160. Moreover, part of the gap between in vitro predictions and
probably binds to the MOR Na+-binding site171. In vivo studies will
in vivo responses depends on location bias161 and systems bias162. Studies
show whether the concept holds to develop safer opioid analgesics.
on receptor signalling in different neuronal compartments and at different
Part a is adapted with permission from ref.172, Elsevier.
brain sites will expand in the future.

a Biased signalling and drug design c Other approaches for better MOR analgesics
Drug 1 Drug 2 Drug 3 • Multifunctional opioids Clinical and
Gi/o-biased opioids
• Dimer-specific opioids abused opioids
R R
R
E2 E3 E2 Opioid
E1 E1
specific to
‘acidic’ receptor
R MOR
Low efficacy Optimal Adverse effects

b Biased signalling at MOR

Signalling regulator
HO Anti-opioid system
N
CH3
O H O Behaviour
O NH
N CH
HO
3
S d Endogenous signalling and allostery at MOR
Morphine Oliceridine Endogenous opioid
Endogenous
O CH3 S
opioid analogue
MOR N N
N H H
HO H3C CH3 2
1
PZM21
β-Arr Gi/o Positive allosteric
CH3 modulator
O
N
S
• Constipation H3 C O N
NH O CH3 O
• Respiratory S
depression Analgesia O Br
O
H3C O Temporally and spatially O CH3
• Reward? Mitragynine pseudoindoxyl controlled enhanced Cl
BMS-986122
• Tolerance and/or dependence? signalling
E, effector; R, receptor.

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 Reviews

Biased agonism development of KOR agonists for pain control and has that drive decision making. Aminergic neurotrans-
A signalling response given KORs a reputation of being associated with the mitter systems (such as the dopamine (DA) and
determined by the ‘dark side’ of emotional and perceptual experience18,19 serotonin (5-HT) systems) have been extensively
conformation of the drug– (Box 2). Overall, the very distinct profiles of MORs, DORs studied in this context. Circuit mechanisms encod-
receptor–effector complex that
engages only a subset of
and KORs have now been clarified, and opportunities in ing reward and/or aversion involve the activity and
cellular effectors. Some opioid research are rapidly advancing. interaction (sometimes bidirectional) of overlapping
high-throughput screening The past decade has witnessed revolutions in GPCR networks32. The opioid system interacts anatomically
programmes have aimed to structure and signalling research20,21. In 2012, the first and functionally with reward–aversion networks33,34,
design novel ‘biased’ drugs with
atomic structures of the MOR22, DOR23, KOR24 and the to maintain hedonic balance, regulate mood states and
improved therapeutic profiles.
structurally related nociceptin/orphanin FQ receptor25 cope with stress (Fig. 2a). Furthermore, the notions
Therapeutic window (Box 3) solved by X-​ray crystallography were published that, for example, endogenous opioids contribute to
Dose range for a drug that (Fig. 1a), opening the way to design opioid drugs with the rewarding effects of pain relief35 and that phys-
allows therapeutic efficacy with entirely novel chemical scaffolds (for example, see ref.26) ical and social pain (such as that associated with
no (or minimal) side effects.
and perhaps to get closer to the ideal analgesic (Box 1). social rejection) share common opioid-​m ediated
Location bias Many signalling effectors activated by opioid receptor mechanisms36,37 are gaining interest.
Bias in receptor signalling stimulation have been identified (for example, those Overall, the opioid system can be considered a
dictated by the location of the in Fig. 1b). Furthermore, new technologies (such as central regulator in basic processes of individual and
receptor in the cell (for example,
neural tracing, connectome analysis, optogenetics and species survival, geared to enhance reward-​b ased
at the surface or in endosomes
or Golgi) and the availability of
chemogenetics) enabled the dissection of neural circuit learning and reduce aversive experiences. Opioid
effectors at this site. organization and function at microscale or macroscale receptors are therefore critical in the emergence of
levels27–29, and the notion of precision medicine is gradually neuropsychiatric disorders that manifest when reward
Systems bias entering the areas of pain30 and addiction31 treatment. and aversion processing are dysfunctional. These
Bias in receptor signalling
driven by anatomical
Opioid research strongly benefits from advances in these pathologies primarily include addiction and depres-
localization within brain circuits domains, and this Review addresses three questions that sion, and opioid receptor targets have therapeutic
subserving the behavioural arguably foster the strongest interest in current opioid potential in both of these disease areas. Opioid recep-
response and the effectors research. First, can we kill pain without addiction using tor function in mood disorders has been reviewed
available at those sites.
MOR-​targeting opiates (addressed in Box 1)? Second, elsewhere38.
Precision medicine how do MORs and KORs operate within the neuro­
Also known as personalized circuitry of addiction? Third, can we bridge human and Opioid receptors and the multiple faces of addiction.
medicine. An innovative animal opioid research in the field of drug abuse? Addiction is a complex, relapsing disorder in which
approach in medicine in which drugs of abuse hijack, overstimulate and compromise
interindividual variability (in
lifestyle, environment and
Opioid receptors in addiction circuits reward-​processing systems and associated networks.
genes) is taken into Experimental evidence from animal research has posi- The disease develops from an initiation phase, during
consideration for disease tioned the role of the opioid system at the centre of reward which the drug produces pleasurable effects and is
prevention and/or treatment. and aversion processing, and has highlighted the notion consumed recreationally. Upon repeated consumption,
that the dysregulation of opioid neurotransmission is a control over drug taking is gradually lost, leading to
Hedonic balance
The equilibrium between
main driver to drug abuse (Fig. 2). compulsive drug seeking and drug taking39,40 (Fig. 2b).
positive and negative affect. Whereas recreational drug use is essentially motivated
A positive hedonic state is Opioid system and reward–aversion in physiology. by reward seeking, drug intake in individuals who are
considered a state of well-​ Searching for reward (such as food, sex and social addicted is also driven by other factors that arise owing
being, whereas a negative
hedonic state is unpleasant.
interactions) and avoiding punishment or discom- to brain adaptations to chronic drug exposure (Fig. 2b).
fort (for example, pain) are two fundamental forces These include reduced self-​control41, enhanced incen-
tive salience (that is, importance of the context) and
habit formation42, altered reward processing and stress
Box 2 | The intriguing hallucinogenic properties of KOR agonists reactivity43, and the emergence of a negative affective
Beyond aversion, kappa-​opioid receptor (KOR) agonists show hallucinogenic properties state upon withdrawal19 or with protracted abstinence
— a facet of KOR function that is unique among opioid receptors. Salvinorin A is a (see ref.44 and references therein).
natural product from the sage Salvia divinorum, or ‘magic mint’, that was long used by Together, alterations of both positive and neg-
the Mazatecs of Oaxaca, Mexico for spiritual rituals and medicinal practice, and was ative affect contribute to the development and
recently discovered to be a specific KOR agonist173,174. Salvinorin A is a highly potent maintenance of addiction, and relevant transmitter
hallucinogen for which the psychoactive effect is comparable to that of lysergic acid
and circuit adaptations are being actively studied 39.
diethylamide (LSD). The use of salvinorin A, which is much less regulated than, for
All three opioid receptors are involved in the process,
example, LSD use, is currently gaining popularity among young individuals in a
recreational context. although with very different contributions (Fig. 2b).
The finding that this KOR agonist has psychoactive effects definitively establishes a The effects of MORs and KORs in regulating addic-
specific role for KORs in higher cognitive and perceptual functions, the dysregulation tion networks and, more importantly, the neuronal
of which is associated with psychiatric disorders such as psychosis, bipolar disorders populations in which these receptors operate, have
and dementia175. This particular KOR function remains poorly understood and adds been well characterized and are discussed below
another aspect to the known role of this receptor in stress responses, mood deficits and (Fig. 2c). DOR-​mediated circuit mechanisms contrib-
drug abuse. The circuits underlying this phenomenon are yet to be characterized. uting to addiction have been less well studied using
Notably, new analogues of salvinorin A with partial agonism or biased ligand properties cell-​specific genetic approaches (only one study 45);
are now proposed for the treatment of neuropsychiatric diseases, including
thus, the current knowledge of DOR involvement in
addiction176; this research is still at an early stage.
addiction is reviewed more briefly.

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Reviews

Reverse pharmacology
An approach in which a
receptor or endogenous ligand
is discovered first, the
physiological function is
determined.
Conditioned place
preference
(CPP). A behavioural paradigm
in rodents that determines the
rewarding or aversive effect of
a drug on the basis of time
spent in a drug-​associated
context after conditioning.
Tetrahydrocannabinol
(THC). The principal
psychoactive component of
cannabis, which produces
central effects by acting at
cannabinoid CB1 receptors.
Psychostimulants
A group of substances
(including cocaine and
amphetamines) that enhance
physical and cognitive
performance. Psychostimulants
are used to treat attention
deficit–hyperactivity disorder.
MORs in reward, motivation and self-​control. MORs
mediate the pleasurable properties of therapeutic and/or
abused opiates in vivo. Importantly, genetic approaches
have demonstrated that these receptors are also necessary
for the rewarding effects of other drugs of abuse
(reviewed elsewhere11,46 and in Supplementary Table 1).
Briefly, Oprm1-knockout mice show lower levels of vol-
untary alcohol drinking and self-​administration (SA)
and fail to express conditioned place preference (CPP) in
response to tetrahydrocannabinol (THC) or nicotine. The
latter molecules primarily activate non-​opioid receptor
targets (that is, cannabinoid receptors and nicotinic
receptors, respectively), and these activated receptors,
in turn, trigger opioid release at appropriate MOR-​
expressing brain sites to produce reward11. The data
are less clear for cocaine and amphetamine, as Oprm1-
knockout mice show decreased SA for these substances,
but no change in CPP (see ref.11), consistent with the
notion that psychostimulants hijack reward systems via
mechanisms that do not necessarily engage MORs, at
least for their rewarding effects47,48.
Genetic approaches have also demonstrated the
essential role of MORs in mediating natural rewards.
The constitutive Oprm1 deletion reduced maternal
attachment in 4–8 day old mutant pups49; furthermore,
adult knockout mice showed impaired social interac-
tions together with several other signs of autistic-​like
behaviours50, confirming the essential function of MORs
in social bonding that was previously suggested by the
pharmacology36,38. Oprm1-null mutants also showed
reduced motivation for both food and sucrose in an SA
paradigm51. Finally, Oprm1-null mutant mice showed no
naloxone aversion in a conditioned place aversion (CPA)
paradigm, indicating that MORs are crucial in mediat-
ing the positive hedonic tone elicited by endogenous
opioids52. Together, the findings above show that MOR
activity both mediates natural rewards and promotes
recreational drug use, with the latter in turn favouring
the onset of drug abuse.
MORs are expressed throughout the addiction cir-
cuitry53 (Fig. 2c). Several brain sites for MOR-​mediated
reward have been identified by local pharmacology, and
these mainly belong to mesocorticolimbic networks54.
Central to this circuitry is the well-​characterized ven-
tral tegmental area (VTA)–nucleus accumbens (NAc;
also known as the ventral striatum) DA pathway. The
prevailing disinhibition hypothesis postulates that
activation of MORs expressed by VTA GABAergic
interneurons relieves the local inhibitory tone and
thus disinhibits DA neurons, which release DA to sig-
nal drug reward55,56. This hypothesis is supported by
many pharmacology and electrophysiology studies57.
However, this is not the only mechanism through which
MORs affect DA signalling, as MORs are also abundant
in brain areas that receive DA neuron projections and,
notably, among NAc neurons that project back to the
VTA58,59. Furthermore, DA-​independent opioid reward
is also documented60–63, but in fact little is known about
MOR-​expressing cells driving opioid reward outside
the VTA.
A few studies using genetic approaches in mice have
recently interrogated MOR function outside the VTA.
In the striatum, MOR expression is robust in DA D1
receptor (D 1R)-expressing medium spiny neurons

Box 3 | The opioid system’s cousin: the opioid-​like receptor and nociceptin/orphanin FQ
The cloning of the opioid-​receptor-encoding genes led to the identification
of homologous G protein-​coupled receptor (GPCR)-encoding genes,
some of which were known (such as those encoding somatostatin
receptors). However, the closest homologue encoded a GPCR for which the
ligand was unknown, thereafter named opioid-​like receptor (ORL1). This
receptor does not bind opioids with high affinity, and therefore cannot be
classified as an opioid receptor. Using reverse pharmacology177, two teams
discovered its endogenous ligand, a 17-amino-​acid peptide named either
orphanin FQ178 or nociceptin179 based on its first reported characteristics
(its peptide sequence and its effect on pain). This was one of the first GPCR
de-​orphanizations, and the receptor and peptide are now classically known
as the nociceptin opioid peptide receptor (NOP) and N/OFQ, respectively.
Strikingly, just as NOP shows the highest homology with the kappa-​
opioid receptor (KOR), the N/OFQ peptide shows sequence similarity
with dynorphin (although lacking the amino-​terminal tyrosine typical of
opioid peptides), suggesting a common ancestor in evolution. Similar to
the opioid receptors, NOP is an inhibitory Gi/o-​coupled GPCR that reduces
neuronal activity and/or neurotransmitter release. Many synthetic NOP
ligands developed in academia and industry180, as well as genetic mouse
mutants, have been used to study the multiple in vivo functions of the NOP
system and its potential interactions with the opioid system (reviewed in
ref.181). NOP-​regulated physiology and pathology cover areas of pain
control, reward processing and drug abuse, stress, anxiety and mood
disorders, feeding and obesity, motor control and cognition, and operate
broadly in the nervous system (reviewed in refs181,182). To the best of our
knowledge, no cell-​specific genetic studies have yet addressed NOP
function in defined brain networks or neuronal populations.
Much evidence supports a role for the N/OFQ–NOP system in addiction
and this has been reviewed extensively180–182. In brief, N/OFQ and NOP
agonists reduce drug reward and basal or drug-​induced (mostly cocaine-​
induced) dopamine release in the nucleus accumbens, alleviate signs of
alcohol withdrawal and diminish stress-​primed or drug-​primed
reinstatement of cocaine place preference, possibly by antagonizing
corticotropin releasing factor (CRF) stress systems. Furthermore, the fact
that N/OFQ blocks morphine-​induced supraspinal analgesia and
conditioned place preference suggests that the N/OFQ–NOP system acts
as an anti-​opioid system for some responses. Indeed, NOP genetic
inactivation or blockade reduces analgesic tolerance to morphine,
confirming functional interactions between the two systems. Rodent
research has therefore positioned the NOP system as a feasible target for
the development of addiction treatments.
At this stage, however, translation to non-​human primates and the clinic
may prove challenging for two reasons. First, the anatomical localization
of the N/OFQ–NOP system seems to be different in rodent, non-​human
primate and human brains. The recent synthesis of positron emission
tomography (PET) tracers for NOP will help to guide clinical trials180.
Second, the effects of N/OFQ on the drug-​abuse-associated aspects of
physiology (such as stress and anxiety) have proved to be complex; both
agonists and antagonists need be examined for their potential
therapeutic utility. The current thinking is that NOP blockade has
potential for treating depression and obesity, whereas NOP activation
may reduce anxiety and help to treat several aspects of addiction,
including a reduction of consumption and the prevention of relapse180,182;
however, the best valid strategy remains open. As an illustration, a NOP
agonist (cebranopadol; phase III) and a NOP antagonist (JTC-801; phase II)
have both reached clinical trials to treat pain, and the NOP antagonist
LY2940094 was tested in phase II trials for major depressive disorders and
for alcohol dependence180.

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 Reviews

(so-​called D1 MSNs) and is barely detectable in DA
D2 receptor (D2R)-expressing MSNs (D2 MSNs)58,59.
Rescuing MOR expression in D1 MSNs of Oprm1-
knockout mice using a bacterial artificial chromosome
Pdyn-​MOR transgene restores morphine CPP and
partially restores remifentanil SA58, suggesting that
MORs expressed in the striatonigral pathway (that is,
by D1 MSNs) are sufficient to mediate opioid reward.
However, whether this receptor population is neces-
sary for drug reward is less clear. Conditional Oprm1

a First solved atomic structure of opioid receptors

MOR–β-FNA DOR–naltrindole KOR–JDTic NOP–C-24
ECL2 ECL2
ECL3 1 ECL2
ECL1 ECL1
7 7 ECL3
EC membrane C-24
1 S–S

1
3
2 5
2 7
3 6 4
2 NPXXY
3
8 DRY ICL3
Helix 8 6
5 ICL1 IC membrane
5 ICL2
6

b The active MOR and signalling effectors

Ca2+ K+ MOR
ECL2 channel channel

AC
Gαi/o Arr GRK
1 G protein- ERK
7 dependent
5 JNK
signalling
6 G protein-
independent
signalling

CAMKII STAT3 PKA PKC p38 MAPK

10 Å

Fig. 1 | Opioid receptor structure and signalling. a | First resolved atomic
structures of inactive opioid receptors and the nociceptin opioid peptide
receptor (NOP); see Box 3 ). The receptors are bound to their specific
antagonists — β-​funaltrexamine (β-​FNA) for the mu-​opioid receptor
(MOR)22, naltrindole for the delta-​opioid receptor (DOR)23 and JDTic for the
kappa-​opioid receptor (KOR)24 as well as the peptide mimetic antagonist
Compound 24 (C-24) for the NOP receptor25. The receptors each have seven
transmembrane domains (numbered). DRY and NPXXY, shown here for the
KOR structure, are conserved motifs important for receptor function.
b | MOR activation and signalling in cells. The left side of the panel shows a
comparison of the seven-​helical arrangement of active (green) and inactive
(blue) forms of the receptor167. The main modification is a 10 Å outward shift
of the intracellular part of transmembrane domain 6, which typically
interacts with cellular effectors and notably the Gα subunit of G proteins.
The conformation of the extracellular receptor domains shows minimal
changes. The structure also revealed a network of polar amino acid residues,
which links the binding site to the cytoplasmic face of the receptor and is
involved in G protein-​coupled receptor (GPCR) signal propagation167. The
switch from inactive to active structures was also probed using solution-​
state NMR , revealing that the conformational changes of transmembrane
domains 5 and 6, the main receptor movements to reach full activation,
require engagement of both the ligand and the G protein mimic in the
complex183. The right side of the panel illustrates MOR signalling in cells.
All three opioid receptors are inhibitory-​type GPCRs, the activation of which
reduces postsynaptic neuronal excitability or presynaptic neurotransmitter
release151. At the cellular level, opioid receptors activate G protein-​
dependent pathways involving both Gαi/o and Gβγ subunits, as well as G
protein-​independent signalling cascades that involve scaffold proteins such
as arrestins (Arr). Altogether, many downstream signalling effectors have
been identified for each receptor8,72,184,185. The scheme illustrates currently
known effectors for MOR and indicates which are G protein-​dependent
(green) or G protein-​independent (red) or whether G protein and/or
Arr dependency is unclear (orange). The cell adapts to repeated
receptor stimulation, leading to desensitization of receptor signalling
(via, for example, receptor trafficking and effector uncoupling) and/or
compensatory upregulation of related cellular pathways72. As for most
GPCRs, opioid receptor activation is subjected to biased agonism; that is,
the cellular and in vivo responses are often agonist-​dependent185. AC,
adenylyl cyclase; CAMKII, calmodulin-​dependent protein kinase II; EC,
extracellular ; ECL , extracellular loop; ERK , extracellular-​signal-regulated
kinases; GRK , GPCR kinase; IC, intracellular ; ICL , intracellular loop; JNK ,
Jun N-​terminal kinase; MAPK , mitogen-​activated protein kinase; PKA ,
protein kinase A ; PKC, protein kinase C; STAT3, signal transducer and
activator of transcription 3. Structures in part a adapted from refs22–25,
Macmillan Publishers Limited. Structure in part b adapted from ref.167,
Macmillan Publishers Limited.

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Reviews

a Opioid system physiology b Opioid receptors in the disease process

Reward Aversion
MOR
Euphoria
• Adaptions to the drug
• Lower reward • Withdrawal • Increased dysphoria
Hedonic tone • Aversive state • Lower mood
Recreational • MOR adaption • Binge
KOR • Higher anxiety
• Dysphoria stress drug use MOR • Intoxication • Increased stress
• Negative affect reactivity
• Lower self-control
DOR Mood • Maladaptive habits KOR–Dyn
• Higher context salience • Preoccupation DOR
• Low anxiety
• Positive affect MOR/DOR/KOR? • Anticipation

c Opioid receptor function in addiction circuits

MOR HIP KOR HIP

FC HB FC HB

CP DRN CP DRN
NAc BNST NAc BNST
VTA VTA

AMY AMY

Preoccupation or anticipation Withdrawal or aversive state Receptor density

Binge or intoxication Low Medium High

Fig. 2 | Opioid receptors in physiology and addiction. a | Opioid receptors
regulate reward and aversion. The opioid system contributes to self and
species survival by promoting reward elicited by natural stimuli (such as food,
sex and social interaction), regulating mood states and facilitating efficient
coping with pain and stress. Mu-​opioid receptors (MORs) and kappa-​opioid
receptors (KORs) oppositely regulate hedonic homeostasis, with MOR
agonists and KOR agonists producing euphoria and dysphoria, respectively.
Stress and drug abuse both enhance KOR–dynorphin (Dyn) signalling,
contributing to an increase in dysphoric states43,83. By contrast, delta-​opioid
receptor (DOR) activity reduces anxiety and depressive states, and regulates
learning and memory14,105. KOR blockade and DOR activation therefore have
the potential to improve emotional responses. Finally , MORs and DORs show
contrasting activities on motor impulsivity (see main text). Opioid receptors
are therefore prime targets for the treatment of addiction and disorders such
as depression38 that are characterized by low-​reward or high-​aversion states.
b | Opioid receptors in the addiction cycle. In highly simplified terms,
addiction can be characterized by ‘low-​reward, high-​aversion’ functioning,
as negative affective states progressively overtake positive affect. A well-​
accepted view from animal research is that drug abuse unfolds as a three-​
stage cycling process, involving binge or intoxication episodes, followed by
withdrawal and a negative affective state when the drug clears, in turn
leading to a preoccupation or craving step, during which desire for the drug
intensifies (craving) and triggers the next intoxication episode (inspired by
refs39,40). Neuroplastic changes occur at all the stages, contributing to
reinforce the addiction process in a vicious cycle; opioid receptors contribute
to all facets of the disease. Animal data (see Supplementary Table 1 for
behavioural models) indicate that MORs drive rewarding properties of opioid
drugs (via direct, on-​target effects) and other drugs of abuse (via indirect,
opioid peptide-​mediated effects) in both recreational consumption and
binge or intoxication, and that repeated MOR activation leads to reduced
drug reward (tolerance) and compensatory adaptations (dependence or
withdrawal symptoms). KOR–Dyn activity is important in the negative affect
that characterizes withdrawal as well as in short-​term or prolonged
abstinence, whereas DORs should limit development of this aversive state.
All three opioid receptors probably influence the preoccupation–
anticipation stage, and are implicated in drug-​biased motivation, habit
formation and loss of control, but these roles are less well understood. In the
latter stage, or relapse to drug taking, evidence supports a role for DORs in
drug cue or context learning103. c | MOR and KOR function in neurocircuits
of addiction. This simplified scheme summarizes animal data involving
genetic or cell-​specific approaches to study opioid receptors in circuits of
addiction-​related behaviours. Similar studies for the DOR are only just
starting45. Brain regions involved in drug abuse are represented (circles) with
their known connectivities (light grey lines) and include most regions studied
in rodent addiction research. Circles are outlined in different colours
depending on whether the brain structure has been associated with binge
or intoxication (orange), withdrawal or aversion (blue), or preoccupation or
anticipation (red) stages and are based on information in refs39,40, with the
addition of the habenula (HB) and dorsal raphe nucleus (DRN), which are
the focus of increasing interest in the context of aversive aspects of
addiction. Receptor density36,54 (represented in a naive mouse brain) is
indicated for each region, and the opioid-​receptor-regulated pathways
identified in the studies discussed in this Review are shown by black arrows.
In brief, MORs in GABAergic interneurons of the ventral tegmental area (VTA)
facilitate dopamine release and drug reward57, whereas MORs in the striatum
(nucleus accumbens (NAc) and caudate putamen (CP)), expressed mainly in
dopamine D1-type neurons58,59, regulate both drug reward (for alcohol and
morphine)58,64 and heroin seeking59. MOR adaptations in the DRN drive
depressive-​l ike states and social withdrawal in protracted heroin
abstinence74. The roles of MOR-​expressing cell populations in regions that
modulate negative affective states, and in regions where the receptor is
abundant (HB, DRN and amygdala (AMY)), remain to be studied. KORs in VTA
dopamine neurons oppose MOR-​stimulating activity at the level of terminals
in the NAc and prefrontal cortex18,89 and disrupt behavioural inhibition94.
KORs in NAc medium spiny neurons differentially gate D1 and D2 neuron
activities and their AMY inputs to negatively regulate motivational
processes91. KORs in DRN serotonin (5-HT) neurons promote stress-​induced
reinstatement to cocaine seeking96,97; KORs in excitatory basolateral
amygdala (BL A) neurons projecting to the bed nucleus of stria terminalis
(BNST) promote anxiety98; and KORs in GABAergic interneurons of the
central AMY contribute to excessive alcohol drinking, probably through
interactions with corticotropin releasing factor systems39,78,83. Finally , MORs
and KORs are also expressed in brain regions involved in contextual memory
and executive functions (including the hippocampus (HIP) and frontal cortex
(FC))78,103, but the potential implication of these receptors in preoccupation
or anticipation has not been studied so far.

504 | AUGUST 2018 | volume 19 www.nature.com/nrn

© 2018 Macmillan Publishers Limited, part of Springer Nature. All rights reserved.

Inhibitory controls
A central component of
executive functions, geared to
inhibit or delay dominant
responses to achieve a goal.
NATuRe RevIewS | NEuROSCiEnCE
deletion from GABAergic forebrain neurons (mostly
from D1 neurons), using a Dlx5/6-Cre driver line in
floxed Oprm1 mice, reduced voluntary alcohol drinking
and alcohol CPP64, indicating that this receptor popula-
tion indeed contributes to alcohol reward. Intriguingly,
the latter genetic manipulation did not impair heroin
CPP — presumably because VTA MORs were intact
in these mice — but did increase seeking behaviour for
heroin and palatable food in SA experiments59, dissoci-
ating MOR-​mediated hedonic effects from motivational
regulation. Thus, in addition to driving pleasurable drug
effects via VTA GABAergic interneurons and, to some
degree, striatal MSNs (depending on the drug and par-
adigm), MORs also regulate motivational aspects of
behaviour, specifically at the level of striatal projecting
neurons. This notion is consistent with sophisticated
pharmacological studies that show that MORs not only
assign hedonic values to rewards, but also contribute to
decision making through coordinated activity in core
and shell compartments of the NAc, which integrate
reward-​related information and guide goal-​directed
actions65.
MORs may also contribute to another facet of
addiction — that is, impaired self-​control — although
this aspect has been less explored. Impulsivity is a critical
susceptibility factor for addiction66, and inhibitory controls
decline with disease development39. Strikingly, Oprm1-
knockout mice showed remarkably lower motor
impulsivity in a signalled nose-​poke task67. The notion
that MORs may facilitate the ‘loss of control’ that
characterizes drug abuse is intriguing. Further studies
are required to identify the key MOR-​expressing neuron
populations responsible for this effect.
An important question is whether, in addition to
facilitating drug reward and drug seeking in the tra-
ditionally studied mesocorticolimbic circuitry, MORs
could also regulate aversion processing in other brain
networks. The site of the densest MOR expression in
the brain is, in fact, the medial habenula (MHb)68. The
MHb and lateral habenula form the habenular com-
plex, which is active in the anticipation of aversive
outcomes and has garnered increasing interest in both
addiction and depression research69,70. As the habenular
complex is considered to be a centre for aversive pro-
cessing and acts as an anti-​reward system — notably,
by inhibiting DA neuron activity — the hypothesis that
MORs may regulate aversion processing, and perhaps
limit aversive responses at the level of MHb neurons,
is appealing, and investigations along these lines have
just begun71.
Finally, an important consideration is that MORs
are chronically activated under repeated drug expo-
sure, and even more so under opiates. With chronic
activation, receptor signalling adapts throughout the
brain, triggering long-​term molecular modifications
within and outside the opioid system72; such neuroa­
daptations to chronic opiates are being intensively
studied73. Behavioural consequences of these adapta-
tions include the development of tolerance (weakening
drug effects with repeated exposure), and dependence
(which manifests in the form of withdrawal symptoms
when the drug is no longer present). Acute withdrawal
© 2018 Macmillan Publishers Limited, part of Springer Nature. All rights reserved.
Reviews
and prolonged abstinence from opiates are both associ­
ated with negative emotional states that can be mode­
lled in rodents44. In this context, MORs in the dorsal
raphe nucleus (DRN), the main serotonergic nucleus,
were shown to be crucial for the development of
despair-​like behaviour and deficits in social interac-
tion in heroin-​abstinent mice74. This finding indicates
that DRN MORs regulate serotonergic transmission
and that adaptations of MOR signalling in the DRN in
response to chronic opiate exposure may profoundly
alter mood during abstinence. This mechanism is parti­
cularly interesting in the area of addiction–depression
comorbidities75.
KORs in dysphoria, stress and depression. In contrast
to MOR agonists, KOR agonists are strongly aversive.
In humans, these drugs induce an acute dysphoric state,
deteriorate mood and have psychotomimetic effects17,76
(Box 2). These KOR activities may have strong implica-
tions for several psychiatric disorders, including drug
abuse, affective disorders and, potentially, psychosis18.
Animal model research has established that the KOR
and dynorphin, the preferred endogenous KOR ligand,
form an ‘anti-​reward’ brain system43,77. Notably, in the
absence of environmental challenge, the endogenous
KOR–dynorphin system has only subtly dysphoric activ-
ity; however, this system is highly responsive to stress78,
and accumulating evidence has shown that addiction
dramatically activates brain stress systems, includ-
ing endogenous KOR signalling43,79–81. In turn, these
events facilitate the emergence of a negative affective
state — which characterizes withdrawal episodes of
the addiction cycle as well as protracted abstinence82 —
and promote escalation of drug consumption, stress-​
induced potentiation of drug reward and stress-​induced
reinstatement of drug seeking83,84.
KORs are expressed at many sites in the addiction
neurocircuitry (Fig. 2c), and a circuit mechanism for
KOR-​mediated dysphoria has long been proposed.
Behavioural analyses have demonstrated CPP and
CPA in response to MOR agonists and KOR agonists,
respectively, and microdialysis studies have revealed
opposing activities for the two types of drugs on
DA release, with MOR agonists disinhibiting VTA DA
neurons at the level of the cell bodies and KOR ago-
nists inhibiting DA-​releasing terminals in the NAc85,86.
These seminal findings may explain why MORs and
KORs have such contrasting effects (that is, euphoria
and dysphoria, respectively), and have established the
notion that endogenous activities of the two receptors
fine-​tune DA tone to regulate hedonic homeostasis.
Accordingly, deletion of Oprk1 from DA neurons
reduced CPA to KOR agonists87, had anxiolytic effects
and enhanced cocaine-​stimulated locomotor activity88.
Electrophysiology demonstrated that KORs in DA
neurons inhibit terminals not only in the NAc, but also
in the prefrontal cortex (PFC)89. As in the NAc, KORs
reduced DA release locally in the PFC via a presynaptic
mechanism and thus contributed considerably to KOR
agonist-​induced CPA90. Therefore, KORs in DA neurons
produce dysphoria via presynaptic inhibition at both
NAc and PFC sites.
volume 19 | AUGUST 2018 | 505
Reviews
Operant photostimulation
Instrumental conditioning in
which animals learn to self-​
administer optogenetic
stimulation; used to determine
whether a neuronal population
mediates reward.
Escalation
In animal research, extended
access to the drug leads to a
daily increase (or escalation) of
drug intake, which is suggested
to reflect loss of control.
506 | AUGUST 2018 | volume 19 www.nature.com/nrn
In the NAc, KORs are expressed by D1 and D2 MSNs
and at the terminals of glutamatergic projections from
the basolateral amygdala (BLA), and dynorphin is
produced by D1 MSNs. A recent optogenetic study
examined KOR function throughout the entire NAc
microcircuitry and demonstrated that two distinct pre-
synaptic KOR-​mediated mechanisms regulate D1 and
D2 MSN activities: one pathway-​specific (affecting BLA
inputs to the NAc) and the other local (affecting MSN
collaterals)91. This study reveals a mechanism whereby
KORs in the NAc dampen excessive MSN activation that
is driven by incentive stimuli or stress, thereby limiting
reward-​seeking behaviour. Thus, in addition to the role
of KORs in influencing euphoria–dysphoria balance,
the notion that KORs negatively regulate motivation is
also gaining support. Another optogenetic manipulation
revealed functional heterogeneity among Pdyn-​positive
neurons (D1 MSNs) in the NAc92. Photostimulation of
these neurons in the dorsal or ventral NAc shell pro-
duced approach or avoidance behaviour, respectively,
in a real-​time place-​preference assay. These opposing
effects were both mediated by KORs and were confirmed
by operant photostimulation. These findings add support
to the emerging notion that reward and aversion mech-
anisms are highly intermingled within the NAc (as was
previously shown for the VTA93) and further support the
view that dysfunctional KOR–dynorphin activity in
the NAc affects motivated behaviours. Another study
in mice used an operant test of cognition (in which lower
rates of response were differentially reinforced) to show
that both stress and KOR activation impair behavioural
inhibition, an effect prevented by Oprk1 gene deletion in
DA neurons94. Thus, KOR blockade might reduce stress-​
induced compulsive behaviours that contribute to drug
seeking and addiction.
KOR activity modulates other brain regions and
transmitter systems (in addition to the DA system) that
are crucial for negative mood and aversive responses
(reviewed in ref.78). First, KORs in the DRN modulate
5-HT transmission, similar to how they modulate DA
release from VTA neurons. Local application of a KOR
agonist decreased 5-HT release in the DRN95, suggest-
ing that a low DA tone may not be the sole cause for
KOR-​mediated dysphoria and that reductions in 5-HT
may also contribute. Accordingly, a KOR antagonist
infused in the DRN abolished the CPA induced by
systemic KOR agonist administration, and prevented
stress-​induced reinstatement of cocaine CPP, through a
mechanism that involved p38 mitogen-​activated protein
kinase (MAPK) in 5-HT neurons and their projections
to the NAc96,97. Second, amygdala-​based mechanisms
contribute to KOR-​mediated anxiety. Oprk1 deletion
in the BLA was anxiolytic in mice, and the anxiolytic
effects produced by photostimulation of the BLA–bed
nucleus of stria terminalis (BNST) pathway were blocked
by systemic administration of a KOR agonist98. The same
study also showed that KORs inhibit excitatory BLA
terminals in the BNST, and that dynorphin in the BNST
thus regulates the activity of BLA–BNST projections
to control the amygdala-​centred anxiety circuit. KOR
activity in the central amygdala (CeA) was also studied
in the context of alcohol dependence. Infusion of a KOR
© 2018 Macmillan Publishers Limited, part of Springer Nature. All rights reserved.
antagonist into the CeA reduced the increase in alcohol
SA elicited by chronic intermittent exposure to alcohol
vapours (a procedure designed to trigger escalation of
alcohol consumption)99. Slice electrophysiology showed
that KORs tonically inhibit local GABAergic transmis-
sion in the CeA via a presynaptic mechanism and has
thus been proposed to regulate the effects of ethanol
there100,101. KORs also interact in a complex manner
with the stress hormone corticotropin releasing factor
(CRF)102. This KOR–CRF signalling interaction is being
increasingly studied for a role in the pro-​addictive effects
of stress, in anxiety disorders and in related psychiatric
conditions (reviewed elsewhere39,78,83).
DORs in mood and learning. Similar to MORs and
KORs, DORs contribute to the development of drug
abuse, although very differently from the two other
receptors. Oprd1-knockout mice show intact mor-
phine SA, intact THC CPP, decreased nicotine SA and
increased alcohol SA (reviewed in refs11,38 and see
Supplementary Table 1). Therefore, contrary to MORs,
DORs are not essential for drug reward. Rather, as pro-
posed by pharmacological studies, DORs seem to have
a complex regulatory role in motivated behaviours65,103.
Unlike Oprm1-knockout mice and Oprk1-knockout
mice, DOR-​null mutants show a remarkable anxiogenic
and depressive-​like phenotype, largely confirmed by
pharmacological approaches14,104, suggesting that DOR
activity normally helps to alleviate the negative mood
associated with acute withdrawal and prolonged absti-
nence. In support of this notion, Oprd1-knockout mice
undergoing protracted abstinence to heroin show exac-
erbated sucrose anhedonia74. Another role of DORs
with potential relevance to addiction is the regulation
of learning and memory (reviewed elsewhere103,105).
DOR-​null mice show impaired spatial learning and,
consistently, reduced drug–context association in CPP
paradigms106. These and other observations suggest that
DOR activity in fact enhances drug–context memories
and facilitates relapse. These findings would suggest that
the DOR is pro-​addictive; however, by alleviating the
low affect associated with withdrawal, DOR activity may
also prevent relapse. In addition, opposing the pheno-
type of MOR-​null mutants, Oprd1-knockout mice show
increased motor impulsivity in a signalled nose-​poke
task67, suggesting that DOR activity increases inhibitory
controls. Thus, altogether, the role of DORs in addiction
is complex.
DORs are expressed in all areas subserving reward
and motivation, mood control, and learning and
memory53,54. The identification of circuit mechanisms
underlying addiction-​r elated functions of DORs
through cell-​specific genetic approaches is just starting.
Only one conditional Oprd1-mutant mouse has been
produced, demonstrating that DORs in GABAergic
forebrain neurons mediate the locomotor-​stimulant
effect of SNC80 (a prototypic DOR agonist), counteract
D1R agonist-​induced hyperactivity and exert an anxio-
genic effect45. Further cell-​targeted genetic studies in the
future may address, for example, the intriguing proposed
role of DORs in stimulus-​based decision-​making at the
level of the BLA–NAc shell circuit65.
 Reviews

Table 1 | Genetic mouse mutants to study opioid receptors in addiction

Mouse line Tool description Findings Refs
Targeting the receptor gene
Knock-​in mice with floxed opioid-​ Dlx5/6-Cre-​mediated conditional knockout • ↑ Motivation for heroin and food SA 59,64

receptor-encoding alleles crossed with of Oprm1 in forebrain GABAergic neurons • ↓ Voluntary alcohol drinking
Cre lines to delete receptor genes in
specific cell populations Dlx5/6-Cre-​mediated conditional knockout • ↓ Anxiety 45

of Oprd1 in forebrain GABAergic neurons • Abolished agonist-​induced locomotor

stimulation
Dat-​Cre-mediated conditional knockout of • Abolished CPA to KOR agonists (U69,593 87,88,186

Oprk1 in DA neurons and U50,488)

• ↑ Locomotor sensitization to cocaine
Knock-​in reporter mice expressing a Oprm1 with carboxy-​terminal mCherry fusion MOR anatomy visualized at brain, neuron 53

functional tagged version of the opioid and subcellular levels

receptor to allow receptor detection
Oprd1 with carboxy-​terminal eGFP fusion • DOR anatomy visualized at brain, neuron 187,188

and subcellular levels

• DOR trafficking in primary neurons
detected in real time
•Receptor trafficking was linked to tolerance
Oprd1 with amino-​terminal HA tag fusion Mouse line characterized 189

combined with a floxed exon 1 for the

conditional deletion of tagged DORs in
targeted neuron populations
Overexpressing the receptor gene
Transgenic lines expressing wild-​type Pdyn-​MOR transgene on an Oprm1-knockout MOR rescue restored morphine reward and 58

opioid receptors background to rescue MOR expression in partly restored remifentanil SA

striatopallidal neurons
Dat-​Cre-dependent viral expression of KORs KOR rescue restored KOR agonist 186

on an Oprk1-knockout background, to rescue (U50,488)-induced CPA

KOR expression in DA neurons
Transgenic lines expressing mutant opioid Light-​activatable opto-​MOR virally expressed Real-​time place preference or avoidance was 190

receptors in GABAergic RMTg and VP neurons dependent on the photostimulated area

Viral KOR-​DREADD expressed in VTA and SN • KOR-​DREADD activation in the midbrain 191,192

or subiculum projections to the NAc (VTA and SN) reduced cocaine-​induced

hyperlocomotion
• KOR-​DREADD activation in subiculum
projections to NAc reduced context-​
induced relapse to alcohol seeking
Targeting opioid-​receptor-expressing or peptide-​expressing neurons
Pomc-​IRES-Crea Cre recombinase expressed in Pomc-​positive Not used in addiction-​related studies 193

neurons that produce β-​endorphin

Penk-​IRES-Crea Cre recombinase expressed in Penk-​positive Not used in addiction-​related studies 193

neurons that produce preproenkephalin

Pdyn-​Cre Cre recombinase expressed in Pdyn-​positive Optogenetic activation of Pdyn-​expressing 92

neurons that produce preprodynorphin cells in the NAc shell produced aversion
(ventral) or preference (dorsal) depending on
the targeted subregion
Oprk1-Cre Cre recombinase expressed in KOR-​positive Mouse line characterized 194

neurons
CPA , conditioned place aversion; DA , dopamine; Dat, gene encoding DA transporter ; Dlx5/6, genes encoding homeobox proteins DLX5 or DLX6; DOR , delta-​
opioid receptor ; DREADD, designer receptor exclusively activated by designer drugs; eGFP, enhanced green fluorescent protein; HA , human influenza
haemagglutinin; IRES, internal ribosome entry site, KOR , kappa-​opioid receptor ; MOR , mu-​opioid receptor ; NAc, nucleus accumbens, Oprd1, gene encoding DOR;
Oprk1, gene encoding KOR; Oprm1, gene encoding MOR; opto-​MOR , optically sensitive MOR; Pdyn, gene encoding preprodynorphin; Penk, gene encoding
preproenkephalin; Pomc, gene encoding proopiomelanocortin; RMTg, rostromedial tegmental nucleus; SA , self-​administration; SN, substantia nigra; VP, ventral
pallidum; VTA , ventral tegmental area. aMice generated by the Allen Institute.

The gap between basic knowledge and treatment
strategies. As described above, anatomical and phar-
macological studies have shown that MORs, KORs and
DORs operate at many sites of addiction circuits,
and genetic approaches have identified several molecu-
lar and neuronal mechanisms underlying MOR and KOR
activities at distinct stages of the disease (Fig. 2b,c). Genetic
tools to manipulate opioid receptors or the specific neu-
rons that express them are developing rapidly107 (Table 1).
More circuit mechanisms subserving MOR-​controlled
and KOR-​controlled behaviours related to drug abuse will
undoubtedly be discovered, and the contribution of DORs
to this circuitry — particularly in emotion, motivation
and learning networks — will also be clarified38,103,105.

NATuRe RevIewS | NEuROSCiEnCE volume 19 | AUGUST 2018 | 507

© 2018 Macmillan Publishers Limited, part of Springer Nature. All rights reserved.
Reviews
Quantitative trait loci
Genomic regions that carry one
or more DNA mutations that
correlate with phenotypic
variations (for example,
behaviour, gene expression
and protein levels).
Machine learning
A research field in which
computers learn to extract
patterns from complex data
sets without being explicitly
programmed for this goal.
Helps biologists to build
predictions.
508 | AUGUST 2018 | volume 19 www.nature.com/nrn
In principle, opioid receptors should be ideal targets The most common and best-​studied variant associ-
to treat drug abuse. MOR blockade could reduce drug ated with drug addiction is the A118G single-​nucleotide
reward, the motivation to seek drugs and compulsive polymorphism (SNP) in the OPRM1 gene (rs1799971,
behaviour. KOR blockade should limit dysphoric states exon 1), which is frequent in non-​African popula-
associated with stress and drug withdrawal, and help tions (16% in Europeans and 38% in Asians) and less
to prevent stress-​induced relapse. Blocking KORs may frequent among African Americans (3%)120. This non-​
also reduce compulsivity (although it could promote synonymous substitution creates a new CpG site for
drug reward). Finally, DOR activation should reduce DNA methylation and leads to an Asn40Asp substitution
anxiety and limit compulsivity but may also facilitate in the extracellular amino-​terminal domain of the recep-
drug–context learning. Although circuit analyses will nottor protein — two possible reasons for the reduced MOR
expression and signalling detected in cell cultures121 and
directly facilitate drug discovery to treat addiction, they
should provide a better understanding of drug effects andpost-​mortem human tissues122 expressing this variant.
help target development of therapeutic drugs to specific To date, many candidate gene studies have correlated
aspects of this complex disorder, including withdrawal, the presence of this particular OPRM1 SNP with opioid
distinct recovery stages and complete abstinence. dependence, responses to opioid pharmacotherapy,
Today, amazingly few opioid drugs are available and alcoholism and nicotine dependence120 (Table 2).
used in clinical practice. Naltrexone (a MOR antagonist) This particular coding OPRM1 SNP, however, may
is a labelled medication that is used to treat alcohol not be the sole factor involved in these associations,
abuse108 and shows some success for other non-​opioid as other intronic and synonymous coding variants
substance or behavioural addictions109 by reducing may affect gene function at the level of transcription,
MOR-​mediated reward. Methadone (a partial MOR mRNA stability and splicing. Recently, a cis-​expression
agonist) and buprenorphine (a partial MOR agonist quantitative trait loci mapping study identified several
and KOR antagonist) show good efficacy to treat opioid other OPRM1 polymorphisms altering OPRM1 expres-
addiction, essentially as replacement therapies110–112. The
sion in PFC samples from the BrainCloud cohort123 and
KOR antagonist activity of buprenorphine is believed tested their association with risk of heroin addiction124.
to contribute to its therapeutic success, and pure KOR Four SNPs were associated with the condition, and
antagonists are being developed to treat addiction84, this association was replicated only when the A118G
anxiety and depression113. One KOR blocker (JDTic) SNP was in the presence of another SNP in intron 1
failed a phase I trial owing to some adverse effects includ-
(rs3778150), indicating that nearby intronic SNPs may
ing tachycardia, and another KOR blocker (CERC-501) instead underlie the inconsistent associations of the
is currently in trials for smoking cessation, treatment-​main A118G SNP with heroin addiction124 and alcohol
resistant depression and anxiety disorder (phase II addiction125. In another study, the rs3778150-rs1799971
for all) 114. The convergence of animal and human haplotype was also associated with several alcohol-​use
research should lead to an expansion of the therapeutic phenotypes126. More recently, a genome-​wide associ-
potential of opioids for drug abuse disorders. ation study (GWAS) revealed a significant association
between a single SNP (rs73568641) and methadone
Bridging the translational gap maintenance therapy in African Americans but not in
Several lines of research will help to bridge the trans- European Americans; interestingly, the closest gene to
lational gap between the genetic and pharmacological this SNP is OPRM1 (ref.127). Future GWAS using novel
studies in animal models described above and the unbiased machine learning approaches should efficiently
development of novel opioid receptor-​targeting strat- address the complexity of allele combination effects.
egies (that is, innovative drugs and/or personalized The A118G SNP was transposed into mice using two
treatments) to treat addiction in the clinic. Notably, knock-​in approaches, together representing one of the
human research includes genetic association studies and very few attempts to model a human vulnerability gene
neuroimaging research, which unequivocally indicate for a psychiatric disorder. In one knock-​in mouse line,
that opioid receptors — particularly MORs — are the major Oprm1 allele was replaced by a mouse allele
associated with the development of addiction. carrying the SNP corresponding to the A118G SNP in
humans (A112G)128. The other experimental design cre-
Gene variability. Drug addiction is partly heritable; ated two humanized mouse models harbouring either the
therefore, genetic factors contribute to addiction vul- major (A118) or minor (G118) human OPRM1 exon 1
nerability115. Over two decades, association studies (ref.129). Mutant mouse phenotypes were analysed in
have established that all opioid-​encoding or opioid-​ depth, but unfortunately the two lines have not been
receptor-encoding genes are loci associated with the compared in similar paradigms and, as such, phenotype
potential risk of opioid addiction116 or other substance comparison is not straightforward (Table 2). Of note are
use disorders117. In the case of opioid dependence, for the parallel findings of increased heroin and nicotine SA
example, risk associations have been found for var- as well as increased heroin-​induced and alcohol-​induced
iants of OPRM1, OPRK1, OPRD1 and PDYN116,118 as DA release in A112G knock-​in mice and humanized
well as POMC and PENK variants (although the latter A118G mice, respectively. Importantly, two studies
two associations require replication)116. Genetic and have directly compared human and mouse phenotypes
epigenetic data from studies on the opioid system have using the humanized mouse model129,130, demonstrat-
been reviewed very recently in the context of addiction ing the potential for translation from mouse to human
biomarker discovery119. research. Striatal DA release in response to an alcohol
© 2018 Macmillan Publishers Limited, part of Springer Nature. All rights reserved.

Receptor bioavailability
Also known as receptor
binding. The quantity of
radiotracer that binds to its
target receptor in positron
emission tomography imaging.
Depends on receptor levels
and occupancy by endogenous
ligands.
NATuRe RevIewS | NEuROSCiEnCE
Table 2 | Effects of the OPRM1 A118G polymorphism in humans and mouse models
Population or model Substance or stimulus
Human studies
Polymorphism ID Opioid
rs1799971, exon 1, A118G
Alcohol
Amphetamine
Nicotine
Mouse studies
A112G knock-​in mice Opioid
Social defeat
Mouse exon 1 replaced by Opioid
human A118G exon 1
Alcohol
Nicotine
DA , dopamine; SA , self-​administration. aThese studies directly compared the human and mouse phenotypes.
challenge was enhanced for G-​allele carriers in mice and
in humans129, and the pleasurable effects of nicotine in
humans or nicotine SA in mice were increased in males,
but not females, of each species130.
The mouse data are certainly complex and do not
exactly match the human findings. Nevertheless, the
hypothesized reductions in MOR availability and
function, in cells and throughout the brain of A118G
carriers, seem to modify the neurobiology of drug
reward. Altered reward processing may be one of the
mechanisms underlying the reported higher risk of
addiction in these individuals.
Neuroimaging. Non-​invasive neuroimaging techniques,
including positron emission tomography (PET) and
MRI, have been used for decades to explore neurotrans-
mitter system activities and whole-​brain functioning in
humans and are used to evaluate, for example, the efficacy
of addiction treatments131. Rodent neuroimaging using
similar approaches has lagged behind owing to limited
resolution but is gaining interest as methods improve.
© 2018 Macmillan Publishers Limited, part of Springer Nature. All rights reserved.
Reviews
Findings Refs
118G allele increased risk of opioid addiction 195–199
No association with or protection from opioid 200
addiction was found
118G allele increased risk of alcohol addiction 195,196,201–204
Only 118G carriers showed a striatal DA 129
response to alcohol
118A allele was associated with increased 205
euphoria and stimulant effect of amphetamine
118G allele was associated with increased 130,206
pleasurable nicotine effects
112GG increased heroin SA and striatal DA 207
release
• 112GG reduced morphine-​induced 128
locomotor stimulation
• Female 112GG carriers did not show place
conditioning to morphine
112GG reduced buprenorphine-​induced 208
locomotor stimulation
112GG mice were resilient to social defeat 209
118GG decreased morphine and hydrocodone 210
reward (via intracranial self-​stimulation) and
DA release in the nucleus accumbens
118GG decreased morphine-​induced 210
locomotor stimulation
Place conditioning to morphine was 211
unchanged
118GG increased alcohol-​induced DA releasea 129
118GG increased efficacy of naltrexone and 212
nalmefene in reducing operant alcohol SA
118GG increased nicotine SA in male but not 130
female micea
PET imaging seeks to map and quantify receptor
occupancy throughout the brain using radiolabelled
tracers. Receptor bioavailability, also known as binding
potential (BP), varies depending on receptor expres-
sion and localization, levels of endogenous ligand and
the binding of exogenous drugs. For opioid receptors,
most reports describe MOR BP using 11C-​carfentanil,
a highly selective, high-​affinity MOR agonist, whereas
DORs or KORs remain difficult to study owing to the
paucity of suitable tracers132. Overall, MOR bioavailabil-
ity is modified by exposure to drugs of abuse (including
opiates, cocaine, alcohol and nicotine), drug craving
and dependence, opioid pharmacotherapy, affective
experiences and pain states (reviewed in refs119,132).
Recently, 11C-​carfentanil PET imaging revealed that
MOR BP is reduced in the frontal cortex of people who
smoke cigarettes and correlates with cigarette liking
and wanting, suggesting a MOR-​mediated activation
mechanism for nicotine reward and dependence133. In a
separate study, a short overnight abstinence period was
sufficient to decrease MOR BP in smokers compared
volume 19 | AUGUST 2018 | 509
Reviews
Effective connectivity
In functional MRI, a measure of
the influence of one brain
region on the activity of
another brain region.
510 | AUGUST 2018 | volume 19 www.nature.com/nrn
with non-​smokers, and the reduction of MOR availabil-
ity in the basal ganglia was correlated with craving and
the severity of nicotine dependence134. Moreover, the
A118G SNP was associated with lower baseline MOR
BP in the NAc and amygdala of smokers134. Another
autoradiographic study showed a reduction of MOR
binding sites in post-​mortem striatal tissue from individ-
uals with alcoholism, paralleling low MOR BP in patients
with alcoholism. PET imaging also revealed that a reduc-
tion in MOR availability in detoxified alcohol-​dependent
patients may be associated with a higher risk of relapse135.
Intriguingly, recent PET studies have also revealed the
role of MORs in natural rewards and behavioural addic-
tions. Lower MOR BP has been consistently reported
among individuals showing pathological gambling or
binge eating136,137, and even in obese individuals who
self-​report food addiction138. High-​intensity training, but
not moderate exercise, decreased MOR BP in fronto­
limbic regions related to reward and emotional process-
ing and correlated with euphoria, consistent in this case
with the notion that endogenous opioid peptide release
may reduce MOR availability139. Along these lines, social
interactions such as social touch140 and social laughter141
modulate MOR availability. Although the interpretation
of these two studies seems complex, the link between
social behaviour and opioidergic activity has been well
established in humans. More generally, PET-​based evi-
dence suggests that MOR-​mediated endogenous opioid
activity facilitates approach-​oriented emotions (such as
anger and pleasure), inhibits avoidance-​oriented emo-
tions (such as fear or sadness) and modulates affiliative
behaviours in humans142. Human studies therefore con-
verge well with animal research to demonstrate that the
MOR is important in reward–aversion processing and
promotes sociability and resilience to stress and that
changes in MOR-​mediated opioidergic activity may
therefore contribute considerably to the development
and maintenance of addiction.
Functional MRI (fMRI) is being increasingly used
to assess brain activation patterns and functional
connectivity, and a variant of fMRI known as phar-
macological MRI (phMRI)143 has allowed the mapping
of the acute effects of opioids in the human brain. In
healthy, opioid-​naive individuals, a morphine challenge
increased and decreased blood-​oxygen-level-​dependent
(BOLD) signals in the NAc (the key reward centre)
and the periaqueductal grey (which processes pain),
respectively144. In a subsequent study, buprenorphine
dose-​dependently increased BOLD signals in several
brain structures (anterior cingulate, frontal cortex, cau-
date putamen, insula and periaqueductal grey), and the
pattern was similar in healthy human participants and in
awake, naive rats, demonstrating the translatability of the
phMRI approach145. In the future, refined drug phMRI
‘signatures’ should guide dose selection for therapeutic
development and clinical trials and provide brain-​level
mechanistic insights into the incompletely understood
and variable in vivo effects of biased MOR agonists that
are currently being developed (Box 1) or MOR agonists
already used in the clinic.
Resting-​state fMRI (rs-​fMRI) has also been used
to investigate brain network activities at rest and
© 2018 Macmillan Publishers Limited, part of Springer Nature. All rights reserved.
to characterize long-​t erm modifications of brain
states with chronic drug exposure. A set of 21 studies
assessing individuals with a history of heroin use was
recently meta-​analysed. All of these studies pointed
to alterations in connectivity that converge to pro-
mote dysfunctional decision-​making and indicated
that network modifications increase with the surveyed
duration of heroin exposure and last for a long time after
becoming abstinent146. Heroin-​abstinent individuals
also all showed differences in the strength of functional
connectivity in brain systems involved in reward pro-
cessing, stress responses and impulsivity147. A recent
study analysed changes in connectivity in individuals
who were formerly addicted to heroin and were under
methadone maintenance therapy. Effective connectivity
was measured for four networks (reward, motivation,
memory and cognitive control). Whereas reward and
cognitive control centres were more weakly connected
with the rest of the brain, learning-​related and memory-​
related centres were more strongly connected than in
heroin-​naive individuals148. These findings are particu-
larly interesting with regards to bridging human and
animal research as similar processes are modelled in
preclinical research (Fig. 2b).
Finally, fMRI is now being developed in mice to
study MOR activation and function, with the unique
advantage of including Oprm1-knockout groups in the
experimental design to isolate on-​target MOR-​mediated
effects. phMRI analysis of oxycodone effects in awake
mice identified an activation pattern149 with anatomi-
cal similarities to the effects of morphine in humans145.
Furthermore, an unbiased rs-​fMRI analysis comparing
whole-​brain activity in anaesthetized mice revealed that
Oprm1-knockout mice show perturbed resting-​state
functional connectivity, with predominant alteration of
the connectivity of reward and aversion centres34. These
recent studies indicate that fMRI is now feasible in
mouse genetic mutants with a resolution comparable to
that in human imaging and open exciting new perspec-
tives for connectome genetics29, therapeutic design143
and the search for biomarkers119 in opioid research.
Conclusions
Research in humans and animal models has firmly
established that opioid receptors are central to reward
and aversion processing in the normal brain and con-
tribute to the development of addiction. The supporting
literature is huge, and this Review focuses on recent pro-
gress and promises for innovative therapeutic discovery
and therapeutic strategies as well as the translational
potential of opioid research in addiction.
In summary, MORs, DORs and KORs contribute
to distinct and specific aspects of the disease: MORs
promote recreational drug use (including opioids and
others) and adapt to chronic activation (leading to tol-
erance and dependence); KORs enable and sustain aver-
sive states of withdrawal and abstinence; DORs improve
mood states and facilitate context learning; and all three
receptors modulate motivation. That both MOR and
KOR activities drive the onset, progression and main-
tenance of addiction is well recognized, whereas the
contribution of DORs remains less straightforward.
 Reviews

In this Review, we have tentatively addressed three
questions. First, can we kill pain without addiction
using MOR-​targeting opiates? Structural and signalling
receptor biology have brought fascinating answers to this
long-​standing question and have guided the creation of
entirely novel chemical entities, and system-​level animal
studies and clinical trials will ultimately reveal the poten-
tial of these novel compounds. Second, how do opioid
receptors operate with the neurocircuitry of addiction?
The identification of neurons and circuits subserving
these activities is rapidly progressing as more genetic
tools become available. Whether recent basic research
efforts in this field will improve treatment strategies in
the future is not clear. However, preclinical circuitry
research has revealed less well-​known roles for opioid
receptors that may help the interpretation of the effects
of compounds in humans and expand the breadth of
indications for the very few therapies that exist as well
as future opioid-​targeting agents for treating addiction.
Third, can we bridge opioid research in the field of drug
abuse in animal models with that in humans? Most
of such research (genetic, epigenetic and neuroimag-
ing) in humans has been focused on MORs, although
research into KORs is increasing. The advent of human-
ized mouse genetic models and rodent neuroimaging is
expected to integrate molecular and circuit mechanisms
into clinical knowledge and to enhance the potential for
personalized addiction treatment.
Published online 22 June 2018

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Acknowledgements
The authors deeply thank the CNRS/INSERM/University of
Strasbourg (France), the US National Institutes of Health
(National Institute of Drug Abuse Grant 05010 and National
Institute on Alcohol Abuse and Alcoholism Grant 16658 to
B.L.K.), the Canada Fund for Innovation and the Canada
Research Chairs (to B.L.K and E.D.), and the Bourgeois family
(B.L.K. is the Bourgeois Chair for Pervasive Developmental
Disorders) for continuous support.
Author contributions
E.D. and B.L.K. researched data for the article, made substan-
tial contributions to the discussion of content, wrote the arti-
cle and reviewed and edited the manuscript before
submission.
Competing interests
The authors declare no competing interests.
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Reviewer information
Nature Reviews Neuroscience thanks E. J. Nestler and the
other anonymous reviewer(s) for their contribution to
the peer review of this work.
Supplementary information
Supplementary information is available for this paper at
https://doi.org/10.1038/s41583-018-0028-x.