Teen Overdose Confirms Arrival of Deadly Opioid in San Francisco

 A 16-year-old boy from San Francisco died in April from the city’s first confirmed overdose involving cychlorphine . The synthetic opioid is considered much more potent than fentanyl, which is already more potent than heroin and other opiates. It has killed dozens of people across the country since 2024. This week, San Francisco police announced they had arrested four suspects accused of supplying the deadly pills in the overdose case. We’ll talk about San Francisco’s  response so far, -and what the arrival of this deadly drug means for a city that has struggled with more than 4,000 drug overdose deaths since 2020.

Guests:

• Heather Knight, San Francisco bureau chief, New York Times – She wrote the recent story, “A Teen Autopsy Marks the Arrival of a Deadly Drug in San Francisco.”
• Daniel Tsai, director, Department of Public Health, San Francisco
• Daniel Ciccarone, professor of of Addiction Medicine, UCSF

This is a computer-generated transcript. While our team has reviewed it, there may be errors.

Alexis Madrigal: Welcome to Forum. I’m Alexis Madrigal. For many years, San Francisco was a model of containing heroin overdoses. Then fentanyl and the pandemic sent overdose numbers spiraling out of control. While it wasn’t fentanyl’s potency alone that caused the surge of deaths, its properties did make overdoses harder to prevent.

Over the past couple of years, public health and public safety efforts have pushed down the numbers of people dying on our streets, which is why it was troubling to hear that there is a new, even more potent drug circulating in San Francisco. It’s called cyclorphine. In April, a 16-year-old boy was the city’s first confirmed overdose involving the drug.

And here to discuss what’s happening and how the city plans to keep tabs on the spread of the drug and other synthetic opioids like it, we’re joined by Heather Knight, San Francisco bureau chief for the New York Times. Of course, she wrote the recent story, “A Teen Autopsy Marks the Arrival of a Deadly Drug in San Francisco.” Welcome, Heather.

Heather Knight: Thank you.

Alexis Madrigal: We’ve also got Dan Tsai, director of the San Francisco Department of Public Health. Welcome, Dan.

Daniel Tsai: Thank you.

Alexis Madrigal: And we’ve got Daniel Ciccarone, who is professor of Family and Community Medicine and Addiction Medicine at UCSF. Good morning.

So, Heather, let’s just start with you. The San Francisco Department of Public Health reported this overdose on April 23rd, saying the tragedy marks the first time that cyclorphine, estimated to be 10 times more powerful than fentanyl and also undetectable by fentanyl strips, had been detected in San Francisco. That was almost six months ago, right? What’s the news that has come out recently about what happened?

Heather Knight: Right. So the city did warn that this drug was here and had killed someone, but didn’t say who it was or the circumstances. And I was able to figure that out. It was a 16-year-old boy named Dante LaCorte. He lived in Lower Nob Hill, and his mother found him dead in his bed the morning of April 7th. He’d just had an overdose. She tried to give him Narcan, it didn’t work, and he passed away.

Alexis Madrigal: Oh, man. And do we know if there have been any other reported deaths, or is that just the one so far?

Heather Knight: Just the one so far. Yeah.

Alexis Madrigal: Dan Tsai, can you tell us more about this drug? And, you know, just where did it come from? We call it new, but actually, you know, it was synthesized quite a while ago, right?

Daniel Tsai: Sure. So to understand cyclorphine and why we’re so concerned about this, it’s helpful to think back to where we are with fentanyl, a category of synthetic opioids that are even more potent than traditionally what folks were using with oxycodone and other products.

And as we’ve seen very much here in San Francisco and across the country, we’ve had a crisis where fentanyl, as many of us have said, has changed the game relative to how potent it is and, therefore, the approaches we’ve needed to think about from a care and treatment standpoint.

And in San Francisco, over the past few years, Heather, as you noted in your article, we’ve had over 4,000 people die of an overdose death, at a point over two people per day. And every single one of those deaths is unacceptable. It’s preventable.

What we see now with cyclorphine, a new category of synthetic opioids potentially 10 times more potent than fentanyl, of course, it’s a great cause for concern. Part of, I think, what the mayor said at a recent press conference in response to just, Heather, a very tragic story, family that you spoke with — thank you for profiling that — is to shout from the rooftops from a public health, public kind of advisory standpoint to make sure folks understand how potent these illicit drugs are.

And that the safest way, especially for parents — I’ve had a lot of parents ask about this — the safest way to protect your kids, or for someone using, is to not take any counterfeit pills, not to take illicit drugs, and that there is treatment, there are options to help folks be able to enter treatment if they are needing to use.

Alexis Madrigal: Daniel, I mean, from your perspective, you know, outside the city, but someone who has studied addiction medicine, how much of a difference does the particular opioid make? You know, like, how different is it to be addicted to heroin versus fentanyl? And, you know, I don’t know if anyone’s actually addicted to cyclorphine in our city right now, but potentially in the future.

Daniel Ciccarone: Um, it makes a huge difference. So these drugs vary by potency. So let’s compare, for example, pharmaceutical oxycodone with heroin. You’ve got 10x plus more potent, moving up to heroin. And that relates to how easy the drug enters the brain.

So that, one, gives you the overdose risk. The easier it enters the brain, the more likely — overdose might, a person might be pushed into an overdose. But the other is it can make that brain, that person, more dependent.

So now we go to fentanyl, which is 25 times more potent than heroin, so greater level of dependency if someone’s a regular consumer of it and greater risk for overdose.

Cyclorphine, we’re — and guesstimating — might be 10 times as potent as fentanyl, so we keep moving up a potency scale within this world of synthetic opioids.

Alexis Madrigal: I mean, is there any upper limit? Like, is cyclorphine near the — I mean, at least my understanding around fentanyl is that one of the things that made it really tricky overdose-wise was that the effect of the high and there wasn’t a lot of room between getting high and dying, right? Like, within your body.

Daniel Ciccarone: That’s true. Is there an upper limit? There doesn’t seem to be a limit to what we call tolerance, the body’s ability to take in a standardized number of milligrams of a morphine molecule.

People have estimated that the average daily fentanyl user is consuming several thousand milligrams equivalent of morphine a day. That said, some people are surviving because of that tolerance, and some people, they’re not.

Alexis Madrigal: Dan, from the city’s perspective, how do you track when a drug like this is coming into the city? I mean, and I know you weren’t the director at that moment when fentanyl started to come into the city, but I think that’s what’s in a lot of people’s minds. It just kind of really did just sweep over the city.

So what are the ways we can know if cyclorphine is growing within the city borders?

Daniel Tsai: Sure. So I think the first piece is, obviously, Heather, as you reported, we saw that through the medical examiner data after someone had overdosed. That was an important signal.

I would say that is not a good way, from a public health standpoint, from a prevention standpoint, to understand what is happening.

We are working right now with Biobot, which is an entity of researchers and scientists that do wastewater testing. Many folks across the country used Biobot during COVID to really understand trends in COVID prevalence across the country with wastewater.

We’ve had some experience here in San Francisco. What we are working with them on, and I would say is rapidly under development at the moment, is being able to use wastewater to detect not just some of the substances that we know well now, like fentanyl and some of the other opioids, but actually to be able to detect cyclorphine and other what we call novel substances in the wastewater.

That is a complicated task. The team is actively working on that, but we are hoping, hoping, hoping the folks doing that research will have an assay available before long, and we will be able to use the wastewater to actually have a signal of: Is it actually being used in the city prior to seeing it in an overdose death?

Alexis Madrigal: We’re talking about San Francisco’s response so far to cyclorphine, what the arrival of the drug means. And, of course, we want to hear from you as well: 866-733-6786.