Drug-Facilitated Robbery or Sexual Assault

Drug-facilitated sexual assault, impaired trauma memory, and implications for mental health treatment

BACKGROUND

Sexual assault (SA) is a highly prevalent global public health problem and a robust predictor of posttraumatic stress disorder (PTSD), substance use disorder (SUD), and suicidality. A large percentage are drug or alcohol facilitated (DFSA), impairing trauma memory and affecting the application of evidence-based treatments. Despite these problems, few have investigated DFSA-specific mental health (MH) needs.

OBJECTIVE

Goals of this study were (1) to identify psychological sequelae characterizing DFSA towards explaining why symptoms have been treatment-refractory, comparing survivors with involuntary substance ingestion (forced, covert: DFSA-I), voluntary ingestion (DFSA-V), and non-DFSA; and (2) to determine how impaired trauma memory relates to the development of PTSD and depression symptoms.

METHOD

Data from a retrospective chart review of 74 adults receiving SA MH services at an outpatient trauma center are presented. The sample includes a 2-year cohort seen acutely at an urban rape treatment center. The study is one of the first to examine therapy records beyond case studies for DFSA. Logistic, Poisson, and negative binomial regression analyses of quantitative data and qualitative thematic analysis of trauma cognitions and treatment foci were conducted.

RESULTS

DFSA-V had five times greater odds of SUD, and notable substance-related self-blame compared to DFSA-I. DFSA-I had prominent relationship distress and self-blame for missing danger of perpetrator drugging. Survivors with impaired trauma memory had significantly fewer hyper-arousal and overall PTSD symptoms, and specifically less hypervigilance. No differences were found in re-experiencing symptoms.

CONCLUSION

Impaired trauma memory is common in DFSA and is associated with fewer baseline hyper-arousal and overall PTS. Despite this, DFSA issues including re-experiencing symptoms that are particularly distressing without the ability to cognitively connect the intrusions contribute to increased treatment needs. Impaired memory limits the application of evidence-based treatments, and collectively these findings call for the development of trauma-specific treatment protocols to enhance recovery for DFSA survivors.

HIGHLIGHTS

Survivors of drug-facilitated sexual assault have prominent PTSD including reexperiencing, though trauma memory may not be encoded. • Those absent trauma memory have less hyperarousal, but DFSA complications explain why it is treatment refractory and inform treatment development.

BDZs, designer BDZs, and Z-drugs: pharmacology and misuse insights

Benzodiazepines (BZDs) are a widely prescribed class of sedative-hypnotics compounds for the treatment of a broad range of conditions as anxiety and obsessive-compulsive disorders, phobias, sleep related problems associated with insomnia and for the management of alcohol and GHB withdrawal. Zolpidem, zopiclone and zaleplon, commonly known as Z-drugs are non-benzodiazepine hypnotic drug with pharmacology similar to BDZs. Despite their usefulness, BDZs and Z-drugs present a potential for abuse and dependence. Moreover, the non-medical use of BDZs is a well-known phenomenon and represents an increasingly widespread public health problem since is associated with an elevated risk of serious health consequences or fatal overdose, especially among specific group of users. The spectrum of BDZs and Z-drugs misuse is extended by new synthetic BDZs, which may pose high risks to users, since the majority have never undergone clinical trials or tests and consequently their pharmacology and toxicology is largely unknown.

The neurochemistry of hypnotic suggestion

A diverse array of studies has been devoted to understanding the neurochemical systems supporting responsiveness to hypnotic suggestions, with implications for experimental and clinical applications of hypnosis. However, this body of research has only rarely been integrated and critically evaluated and the prospects for the reliable pharmacological manipulation of hypnotic suggestibility remain poorly understood. Here we draw on pharmacological, genotyping, neuroimaging, and electrophysiological research to synthesize current knowledge regarding the potential role of multiple widely-studied neurochemicals in response to suggestion. Although we reveal multiple limitations with this body of evidence, we identify converging results implicating different neurochemical systems in response to hypnotic suggestion. We conclude by assessing the extent to which different results align or diverge and outline multiple avenues for future research. Elucidating the neurochemical systems underlying response to suggestion has the potential to significantly advance our understanding of suggestion.

Group-Targeting SERS Screening of Total Benzodiazepines Based on Large-Size (111) Faceted Silver Nanosheets Decorated with Zinc Oxide Nanoparticles

Rapid, quantitative, and group-targeting detection of total benzodiazepines (BZDs) is critical to create an accurate judgement in emergent medical and forensic settings. Large-size (111) faceted Ag nanosheets decorated with small ZnO nanoparticles were designed as the prominent surface-enhanced Raman scattering substrate, which possessed advantages of specific metal facets and additional charge-transfer (CT) effect from the semiconductor. The vital and bridge role of ZnO in the CT effect was systematically studied via experimental investigations and molecular dynamics simulation, which proves the essentiality of an appropriate ZnO decoration density. Upon determining optimal Ag NS/ZnO hybrids, a calibration curve of estazolam was established with a 0.5 nM detection limit. Based on the obtained curve, group-targeting screening was achieved toward total concentrations of five BZDs (estazolam, oxazepam, alprazolam, triazolam, and lorazepam). Importantly, the total concentrations of BZDs in mice serum were accurately monitored with changing analytical time during the metabolic process, which was in agreement with the tendency measured by liquid chromatography with tandem mass spectrometry.

Hair analysis in toxicological investigation of drug-facilitated crimes in Denmark over a 8-year period

Hair can serve as a specimen for identifying past drug exposure. Segmental hair analysis may differentiate a single exposure from chronic use. Consequently, segmental hair analysis is useful for disclosing a single drug ingestion, as well as for determining repeated exposures in drug-facilitated crimes (DFCs). This paper presents an overview of toxicological investigations that have used hair analysis in DFC cases from 2009 to 2016 in Denmark. Hair concentrations were determined for 24 DFC-related drugs and metabolites, including benzodiazepines and other hypnotics, antihistamines, opioid analgesics, antipsychotics, barbiturates, and illicit drugs from DFC cases. Drug detection in hair in DFC cases following a single or few intakes of chlorprothixene, codeine, diphenhydramine, oxazepam, oxycodone, promethazine, and phenobarbital is reported for the first time in forensic toxicology. A literature review on concentrations in the published DFC-related hair cases and on concentrations in hair of these substances after single and multiple doses is included. These cases demonstrate the value of segmental hair analysis in DFCs and facilitate future interpretations of results.

LC-MS-MS with Post-Column Reagent Addition for the Determination of Zolpidem and its Metabolite Zolpidem Phenyl-4-carboxylic Acid in Oral Fluid after a Single Dose

A rapid, selective and sensitive LC-MS-MS method with a post-column addition of acetonitrile was developed and fully validated for the quantitative determination of zolpidem and its major metabolite, zolpidem phenyl-4-carboxylic acid (ZPCA), in oral fluid. Preliminary sample treatment was limited to a simple dilution of 1 mL oral fluid specimen aliquots with methanol. Chromatography was performed on a Capcell Pak C18 MGII column (250 × 2.0 mm, 5 μm i.d., Shiseido, Tokyo, Japan) with isocratic elution using a water-acetonitrile mobile phase with 0.1% formic acid, 5% acetonitrile and 20 mM ammonium acetate in an aqueous phase at a flow rate of 0.4 mL/min. Acetonitrile was added post-column at a flow rate of 0.4 mL/min to enhance ionization of the analytes in the MS source. Detection was carried out on a QTrapTM 6500 mass spectrometer in positive ionization mode. Good linearities were generated over the range of 0.05-200 ng/mL for zolpidem and 0.1-200 ng/mL for ZPCA. Limit of detection for zolpidem and ZPCA were 0.01 ng/mL and 0.05 ng/mL, respectively, whereas LLOQs were 0.05 ng/mL and 0.1 ng/mL, respectively. This method meets the required criteria for bioanalytical analyses to be used for clinical and forensic purposes. Application of this method was demonstrated by testing authentic samples collected after a single oral dose to obtain insights into the general detectability and detection windows of zolpidem and ZPCA in oral fluid.

Benzodiazepines revisited--will we ever learn?

AIMS

To re-examine various aspects of the benzodiazepines (BZDs), widely prescribed for 50 years, mainly to treat anxiety and insomnia. It is a descriptive review based on the Okey Lecture delivered at the Institute of Psychiatry, King's College London, in November 2010.

METHODS

A search of the literature was carried out in the Medline, Embase and Cochrane Collaboration databases, using the codeword 'benzodiazepine(s)', alone and in conjunction with various terms such as 'dependence', 'abuse', etc. Further hand-searches were made based on the reference lists of key papers. As 60,000 references were found, this review is not exhaustive. It concentrates on the adverse effects, dependence and abuse.

RESULTS

Almost from their introduction the BZDs have been controversial, with polarized opinions, advocates pointing out their efficacy, tolerability and patient acceptability, opponents deprecating their adverse effects, dependence and abuse liability. More recently, the advent of alternative and usually safer medications has opened up the debate. The review noted a series of adverse effects that continued to cause concern, such as cognitive and psychomotor impairment. In addition, dependence and abuse remain as serious problems. Despite warnings and guidelines, usage of these drugs remains at a high level. The limitations in their use both as choice of therapy and with respect to conservative dosage and duration of use are highlighted. The distinction between low-dose 'iatrogenic' dependence and high-dose abuse/misuse is emphasized.

CONCLUSIONS

The practical problems with the benzodiazepines have persisted for 50 years, but have been ignored by many practitioners and almost all official bodies. The risk-benefit ratio of the benzodiazepines remains positive in most patients in the short term (2-4 weeks) but is unestablished beyond that time, due mainly to the difficulty in preventing short-term use from extending indefinitely with the risk of dependence. Other research issues include the possibility of long-term brain changes and evaluating the role of the benzodiazepine antagonist, flumazenil, in aiding withdrawal.

Drugs involved in drug-facilitated crimes: part I: alcohol, sedative-hypnotic drugs, gamma-hydroxybutyrate and ketamine. A review

SUMMARY

In recent years, there has been a notable increase in the number of reports of drug-facilitated crimes (DFCs). Usually, individuals report that they were robbed or assaulted while incapacitated by drugs. Most often, these cases have involved drugs that have the ability to produce an effect that leaves the victim in a semiconscious or unconscious state. It is reasonable to assume that the purpose of drug-induced incapacitation is probably largely unchanged with time. This covers the full range of property offences (particularly theft) and crimes against the person. What have changed are the drugs themselves: the number; type; their accessibility; effects and detection. The purpose of this review is to explore the different aspects related to the involvement and use of ethanol, sedative-hypnotics drugs, gamma-hydroxybutyrate (GHB) and ketamine in DFCs or offences, which may help people working in this field to expand their knowledge for better understanding of the nature of these crimes or offences.

Late-life insomnia: a review

Aging is associated with substantial changes in sleep patterns, which are almost always negative in nature. Typical findings in the elderly include a reduction in the deeper stages of sleep and a profound increase in the fragmentation of nighttime sleep by periods of wakefulness. The prevalence of specific sleep disorders increases with age, such as a phase advance in the normal circadian sleep cycle, restless legs syndrome, and obstructive sleep apnea, which is increasingly seen among older individuals and is significantly associated with cardio- and cerebrovascular disease as well as cognitive impairment. Elderly patients with sleep disturbances are often considered difficult to treat; yet, they are among the groups with the greatest need of treatment. Management of sleep disturbances begins with recognition and adequate assessment. Hypnotic drugs have clearly been shown to improve subjective and objective sleep measures in short-term situations, but their role in chronic insomnia still remains to be further defined by research evidence. Non-pharmacological treatments, particularly stimulus control and sleep restriction, are effective for conditioned aspects of insomnia and are associated with a stable, long-term improvement in sleep. This review delineates the common causes of disordered sleep in older individuals, and effective diagnostic approaches and treatments for these conditions.

Knock-out drugs: their prevalence, modes of action, and means of detection

BACKGROUND

Knock-out drugs are used to facilitate the commission of a crime, generally either robbery or sexual assault. Although media reports on the use of knock-out drugs have become more frequent, there are no robust epidemiological data on the incidence of drug-facilitated robbery or sexual assault, presumably because many crimes of these types do not enter into official statistics.

METHODS

The authors describe the modes of action and toxicological means of detection of the substances most frequently used as knock-out drugs on the basis of a selective literature research on the terms "drug-facilitated sexual assaults" (DFSA) and "drug-facilitated crimes" (DFC).

RESULTS

The most frequently used drug in cases of sexual assault is still alcohol (ca. 40% to 60%), followed by illegal drugs (cannabis, cocaine). The presence of involuntarily consumed medications and drugs of abuse is demonstrated by routine toxicological analysis only in relatively few cases (ca. 2%). The substances most commonly found are benzodiazepines, followed by other hypnotics. In Europe, the illegal substance gamma-hydroxybutyric acid (GHB, "Liquid Ecstasy"), often mentioned as a "date-rape drug," is only rarely detected with sufficient medicolegal certainty. This may be due to its rapid elimination (it is detectable in blood for up to 8 hours, in urine for up to 12 hours) as well as its physiological occurrence in the body. If the toxicological analysis of blood and urine is negative in a case of suspected DFSA, then the analysis of a hair sample about four weeks after the assault can detect the presence of drugs consumed at that time. If the victim has long hair, it may be possible to detect knock-out drugs taken more than four weeks earlier. In Europe, convictions for drug-facilitated crimes are comparatively rare, mainly because of the difficulty of demonstrating conclusive evidence.

CONCLUSIONS

A careful medical history and physical examination and the careful taking of biological samples for toxicological analysis form the basis for the detection of drug-facilitated crimes.

Hypnosedative-induced complex behaviours : incidence, mechanisms and management

A number of news items and case reports describing complex behaviours (e.g. sleep driving, sleep cooking, sleep eating, sleep conversations, sleep sex) associated with the use of hypnosedative medications have recently received considerable attention. Regulatory agencies examining these reports have subsequently issued warnings regarding the potential of hypnosedative agents to produce complex behaviours. Despite these warnings, little is known about the likelihood, presentation, treatment or prevention of hypnosedative-induced complex behaviours. The purpose of this review is to evaluate the published evidence regarding the clinical presentation, incidence, mechanism and management of sleep-related behaviours induced by nonbenzodiazepine receptor agonists (NBRAs).Review of the literature identified ten published case reports of NBRA-induced complex behaviours involving 17 unique patients. Fifteen of the 17 patients described in the case reports had taken zolpidem, one had taken zaleplon and one had taken zopiclone. The complex behaviours most commonly reported were sleep eating, sleepwalking with object manipulation, sleep conversations, sleep driving, sleep sex and sleep shopping. Elevated serum concentrations resulting from increased medication dose or drug-drug interactions appeared to play a role in some but not all cases. Sex, age, previous medication exposure and concomitant disease states were not consistently found to be related to the risk of experiencing a medication-induced complex behaviour.From a pharmacological standpoint, enhancement of GABA activity at GABAA receptors (particularly alpha1-GABAA receptors) is a possible mechanism for hypnosedative complex behaviours and amnesia. Evidence suggests that complex behaviour risk may increase with both dose and binding affinity at alpha1-GABAA receptors. The amnesia that accompanies complex behaviours is possibly due to inhibition of consolidation of short- to long-term memory, suggesting that the risk may extend to non-GABAergic hypnosedatives. While amnesia and GABA-related receptor actions are the most frequently discussed mechanisms for complex behaviours in the literature, they do not fully explain such behaviours, suggesting that other mechanisms and factors probably play a role.A number of potential strategies are available to manage or prevent hypnosedative-induced complex behaviours. These include lowering the dose of, or stopping, the offending hypnosedative, switching to a different hypnosedative, treating patients with other classes of medications, using nonpharmacological treatment strategies for patients with sleep disorders, examining drug regimens for potential drug interactions that may predispose patients to experiencing complex behaviours, administering hypnosedative medications appropriately and selecting patients more carefully for treatment in terms of their likelihood of experiencing medication adverse effects.

The involvement of drugs and alcohol in drug-facilitated sexual assault: a systematic review of the evidence

The rate of drug-facilitated sexual assault (DFSA; when an incapacitating drug is administered surreptitiously to facilitate sexual assault) is perceived to be increasing in the United Kingdom and elsewhere, causing international concern. This article examines evidence that quantifies the contribution of drugs in instances of alleged DFSA, identifies the substances involved, and discusses the implications of these findings. Of 389 studies examined, 11 were included in this review. The only study to consider covert drugging reported that 2% of alleged DFSA cases were attributable to surreptitious drug administration. Other studies failed to remove voluntary drug consumption from their cohort, biasing results. A study by the United Kingdom's National Forensic Services found no evidence to suggest that flunitrazepam (Rohypnol) had been used for DFSA during its 3-year investigation. In the United States, flunitrazepam is used recreationally, providing a likely explanation for its presence in samples of some alleged DFSA victims.

[Drug-facilitated crime and sexual abuse: a pediatric observation]

Drug-facilitated crime in sexual assault situations remains insufficiently recognized by physicians. In the possible context of an assault and in front of recent neuropsychicological disturbances in a child, such an issue has to be considered. The quality of sampling, the use of ultra-sensitive and specific toxicologic methods and a clinical-biological collaboration allow to recognize this form of delinquency whose consequences are both medical and legal.

Criminal poisoning: drug-facilitated sexual assault

Drug-facilitated sexual assault (DFSA) is a complex and ever-prevalent problem presenting to emergency departments. Emergency personnel should consider DFSA in patients who are amnestic to the specific details of the event following a reported sexual assault. The presence of ethanol or a positive routine drug screen in a sexual assault victim does not exclude the potential of a surreptitious drug being present. In addition, a negative routine drug screen does not exclude all potential agents that are used in DFSA. This article discusses agents reported in DFSA. It is imperative for emergency personnel to clearly document the history and the presenting signs and symptoms to assist laboratory personnel to hone in and detect the correct agent used in a DFSA.

Compulsive activity and anterograde amnesia after zolpidem use

BACKGROUND

Zolpidem is a selective GABAAalpha1 receptor modulator used for its hypnotic-sedative properties. Zolpidem has side effects that are similar but not identical to the benzodiazepines. We report the first cases of compulsive activity combined with anterograde amnesia after the use of zolpidem.

CASE REPORT

Three women experienced anterograde amnesia and compulsive repetitive behaviors after zolpidem use. These activities consisted of cleaning, shopping, and eating. These behaviors stopped after discontinuation of the zolpidem.

CONCLUSION

These reports demonstrate that compulsive activity combined with anterograde amnesia may be associated with the use of zolpidem. Physicians and pharmacists should be aware of this potential side effect.

Toxicological investigation of drug-facilitated sexual assaults

Drug-facilitated sexual assaults have drawn a lot of attention during the last years. The role of the non-forensic doctors in the early recognition and management of such cases is crucial. Diagnosis assisted by samplings must be ascertained without delay, in victims initially brought to the emergency room for a sleepy state, a suspected abuse of drug or a pseudo-alcoholic clinical state. Further, where amnesia is present, it may be prudent to assume that sexual activity has occurred and offer pregnancy and sexually transmitted disease prophylaxis. Forensic doctors should entertain the possibility of poisoning in any presentation involving amnesia. Forensic toxicological laboratories should develop sensitive and specific methods to assure a low threshold of detection of the drugs. The awareness of a delinquent or criminal use of alcohol and/or drugs could permit a better medical recognition, so that proper and timely forensic examination is achieved, and adequate evidence is collected for the establishment of an effective investigation and prosecution.

La soumission chimique: une revue de la littérature

The aim of this review is to describe the present knowledge about chemical submission. The number of scientific publications on this phenomenon has increased over the last 10 years. Perpetrators choose drugs which act rapidly, produce desinhibition, sedation, and anterograde amnesia during the abuse. Ethanol and benzodiazepines are the most frequently used. A few drugs, including flunitrazepam and gamma-hydroxybutyric acid (GHB), have received widespread media coverage. Toxicological investigations on blood, urine or hair samples allow to detect the substance used. Every effort should be made to collect appropriate specimens as quickly as possible. Gas chromatography-mass spectrometry is at present the most appropriate analytical method to detect these drugs in a biological specimen.

Major Metabolites of Zolpidem: Expeditious Synthesis and Mass Spectra

An expeditious route to the two major metabolites of Zolpidem-and readily applicable to the synthesis of the drug-was established via a cyclization reaction between a 2-aminopyridine and a suitable alpha-bromoacetophenone. The structures of the target compounds were confirmed from a 2D (1)H-(15)N NMR correlation. Their mass spectra contribute to a reliable toxicological identification of the drug in the case of drug-facilitated crimes.