Use and abuse of flunitrazepam

Potentiation of the depressant effect of alcohol by flunitrazepam in rats: an electrocorticographic, respiratory and electrocardiographic study

Alcohol, a widely commercialized psychotropic drug, and the benzodiazepine Flunitrazepam, an anxiolytic widely prescribed for patients with anxiety and insomnia problems, are well known drugs and both act on the central nervous system. The misuse and the association of these two drugs are public health concerns in several countries and could cause momentary, long-lasting and even lethal neurophysiological problems due to the potentiation of their adverse effects in synergy. The present study observed the result of the association of these drugs on electrophysiological responses in the brain, heart, and respiratory rate in Wistar rats. 8 experimental groups were determined: control, one alcohol group (20% at a dose of 1 ml/100 g VO), three Flunitrazepam groups (doses 0.1; 0.2 and 0.3 mg/kg) and three alcohol-Flunitrazepam groups (20% at a dose of 1 ml/100 g VO of alcohol, combined with 0.1; 0.2 and 0.3 mg/kg of Flunitrazepam, respectively). The results showed that there was a more pronounced reduction in alpha and theta wave power in the alcohol-Flunitrazepam groups, a decrease in the power of beta oscillations and greater sedation. There was a progressive decrease in respiratory rate linked to the increase of Flunitrazepam dose in the alcohol-Flunitrazepam associated administration. It was observed alteration in heart rate and Q-T interval in high doses of Flunitrazepam. Therefore, we conclude that the association alcohol-Flunitrazepam presented deepening of depressant synergistic effects according to the increase in the dose of the benzodiazepine, and this could cause alterations in low frequency brain oscillations, breathing, and hemodynamics of the patient.

Sedative-Hypnotic Agents That Impact Gamma-Aminobutyric Acid Receptors: Focus on Flunitrazepam, Gamma-Hydroxybutyric Acid, Phenibut, and Selank

There are many nonopioid central nervous system depressant substances that share a gamma-aminobutyric acid (GABA) receptor-related mechanism of action. These sedatives-hypnotics can be indicated to treat anxiety, seizures, depression, and insomnia but are also used as substances of abuse and used to facilitate sexual assault. Barbiturates, methaqualone, and glutethimide were among the first type A GABA receptor-mediated sedative-hypnotics. Their clinical use was limited for most indications by serious adverse events and strong abuse potential but continue to be used illicitly around the world. The benzodiazepines supplanted barbiturates for most indications because they were less likely to cause severe adverse events in monotherapy. Flunitrazepam is a newer benzodiazepine that is preferentially used recreationally and to facilitate sexual assault. Flunitrazepam has greater potency and higher affinity for the type A GABA receptor than most benzodiazepines. Gamma-hydroxybutyric acid is sought illicitly for its hypnotic, euphoric and anabolic effects as well as to facilitate sexual assault. When any of these GABAergic drugs are used in high doses or with other sedative hypnotic agents, respiratory depression, coma, and death have occurred. Chronic use of these GABAergic drugs can lead to significant withdrawal syndromes. Phenibut and selank are poorly studied Russian drugs with GABAergic mechanisms that are inexplicably sold to US consumers as dietary supplements. Poison control center calls regarding phenibut have increased substantially over the past 5 years. Desired euphoriant effects account for the recreational and illicit use of many GABA-modulating agents. However, illicit use can lead to significant toxicities related to abuse, dependence, and subsequent withdrawal syndromes. Significant evaluation of developing agents with GABA properties should be conducted to determine abuse potential before public access ensues.

Designer benzodiazepines versus prescription benzodiazepines: can structural relation predict the next step?

Designer benzodiazepines are a part of the recently discovered abuse synthetic drugs called Novel Psychoactive Substances (NPS) which need to be controlled due to their constantly growing market. Most of them are derived from the medically approved benzodiazepines used nowadays yet, may possess stronger effects, more toxicity, and longer durations of action. Some differences have also been observed in their detection and characteristics, in addition to the variations discovered in postmortem redistribution and drug stability. All these major alterations in features can result from only minor structural modifications. For example, a classic benzodiazepine (BZD) like diazepam only lacks one fluorine atom which exists in its derivatized designer drug, diclazepam, making substantial differences in activity. For this reason, it is essential to study the designer drugs in order to identify their dangers and distinguish them thus rule out their abuse and control the spread of such drugs. This review would highlight the distinct characteristics of some of the most commonly abused designer benzodiazepine analogies in relation to their original prescription BZD compounds.

All solid-state miniaturized potentiometric sensors for flunitrazepam determination in beverages

Flunitrazepam is one of the frequently used hypnotic drugs to incapacitate victims for sexual assault. Appropriate diagnostic tools should be available to victims regarding the growing concern about "date-rape drugs" and their adverse impact on society. Miniaturized screen-printed potentiometric sensors offer crucial point-of-care devices that alleviate this serious problem. In this study, all solid-state screen-printed potentiometric flunitrazepam sensors have been designed. The paper device was printed with silver and carbon ink. Formation of an aqueous layer in the interface between carbon-conducting material and ion-sensing membrane nevertheless poses low reproducibility in the solid-contact electrodes. Accordingly, poly(3,4-ethylenedioxythiophene) (PEDT) nano-dispersion was applied as a conducting hydrophobic polymer on the electrode surface to curb water accumulation. Conditioning of ion-sensing membrane in the vicinity of reference membrane has been considered carefully using special protocol. Electrochemical characteristics of the proposed PEDT-based sensor were calculated and compared favorably to PEDT-free one. The miniaturized device was successfully used for the determination of flunitrazepam in carbonated soft drinks, energy drink, and malt beverage. Statistical comparison between the proposed sensor and official method revealed no significant difference. Nevertheless, the proposed sensor provides simple and user-friendly diagnostic tool with less equipment for on-site determination of flunitrazepam.

Forensic analysis of beverage stains using hyperspectral imaging

Documentation and analysis of crime scene evidences are of great importance in any forensic investigation. In this paper, we present the potential of hyperspectral imaging (HSI) to detect and analyze the beverage stains on a paper towel. To detect the presence and predict the age of the commonly used drinks in a crime scene, we leveraged the additional information present in the HSI data. We used 12 different beverages and four types of paper hand towel to create the sample stains in the current study. A support vector machine (SVM) is used to achieve the classification, and a convolutional auto-encoder is used to achieve HSI data dimensionality reduction, which helps in easy perception, process, and visualization of the data. The SVM classification model was re-established for a lighter and quicker classification model on the basis of the reduced dimension. We employed volume-gradient-based band selection for the identification of relevant spectral bands in the HSI data. Spectral data recorded at different time intervals up to 72 h is analyzed to trace the spectral changes. The results show the efficacy of the HSI techniques for rapid, non-contact, and non-invasive analysis of beverage stains.

Early Detection of Prescription Drug Abuse Using Doctor Shopping Monitoring From Claims Databases: Illustration From the Experience of the French Addictovigilance Network

Opioid analgesics and maintenance treatments, benzodiazepines and z-drugs, and other sedatives and stimulants are increasingly being abused to induce psychoactive effects or alter the effects of other drugs, eventually leading to dependence. Awareness of prescription drug abuse has been increasing in the last two decades, and organizations such as the International Narcotics Control Board has predicted that, worldwide, prescription drug abuse may exceed the use of illicit drugs. Assessment of prescription drug abuse tackles an issue that is hidden by nature, which therefore requires a specific monitoring. The current best practice is to use multiple detection systems to assess prescription drug abuse by various populations in a timely, sensitive, and specific manner. In the early 2000's, we designed a method to detect and quantify doctor shopping for prescription drugs from the French National Health Data System, which is one of the world's largest claims database, and a first-class data source for pharmacoepidemiological studies. Doctor shopping is a well-known behavior that involves overlapping prescriptions from multiple prescribers for the same drug, to obtain higher doses than those prescribed by each prescriber on an individual basis. In addition, doctor shopping may play an important role in supplying the black market. The paper aims to review how doctor shopping monitoring can improve the early detection of prescription drug abuse within a multidimensional monitoring. The paper provides an in-depth overview of two decades of development and validation of the method as a complementary component of the multidimensional monitoring conducted by the French Addictovigilance Network. The process accounted for the relevant determinants of prescription drug abuse, such as pharmacological data (e.g., formulations and doses), chronological and geographical data (e.g., impact of measures and comparison between regions), and epidemiological and outcome data (e.g., profiles of patients and trajectories of care) for several pharmacological classes (e.g., opioids, benzodiazepines, antidepressants, and methylphenidate).

Care of the Adolescent After an Acute Sexual Assault

Sexual violence is a broad term that encompasses a wide range of sexual victimizations. Since the American Academy of Pediatrics published its last policy statement on sexual assault in 2008, additional information and data have emerged about sexual violence affecting adolescents and the treatment and management of the adolescent who has been a victim of sexual assault. This report provides new information to update physicians and focuses on the acute assessment and care of adolescent victims who have experienced a recent sexual assault. Follow-up of the acute assault, as well as prevention of sexual assault, are also discussed.

Non-prescribed use of psychoactive prescription drugs among drug-impaired drivers in Sweden

AIMS

To determine the prevalence of non-prescribed drug use among subjects suspected of drug-impaired driving with a psychoactive prescription drug, and to identify associated factors.

METHODS

Subjects investigated for drug-impaired driving in Sweden during 2006-2009 with a confirmed intake of diazepam, flunitrazepam, tramadol, zolpidem or zopiclone were identified using the Swedish Forensic Toxicology Database. Information on dispensed prescription drugs was retrieved from the Swedish Prescribed Drug Register. Non-prescribed use was our outcome, defined as a psychoactive prescription drug intake confirmed by toxicological analysis in a subject by whom it was not dispensed in the 12 months preceding the sampling. Prevalence proportions were calculated for each drug and logistic regression was used to identify associated factors.

RESULTS

In total, 2225 subjects were included. The median age (range) was 34 (15-80) years and 1864 (83.8%) subjects were male. Non-prescribed use was found in 1513 subjects (58.7%); for flunitrazepam 103 (76.3%), diazepam 1098 (74.1%), tramadol 192 (40.3%), zopiclone 60 (29.7%), and zolpidem 60 (21.2%) subjects, respectively. Younger age and multiple-substance use were associated with non-prescribed use, whereas ongoing treatment with other psychoactive drugs was negatively associated with non-prescribed use.

CONCLUSIONS

Non-prescribed use of psychoactive prescription drugs was common in subjects suspected of drug-impaired driving and was more frequent for benzodiazepines and tramadol compared to zolpidem and zopiclone. The young and multi-substance users were more likely, whereas subjects with ongoing prescribed treatment with other psychoactive drugs were less likely, to use non-prescribed drugs.

Enhancing sexual desire and experience: an investigation of the sexual correlates of gamma-hydroxybutyrate (GHB) use

OBJECTIVE

Various studies have dealt with gamma-hydroxybutyrate's (GHB) potential role in sexual assaults, while the sexual correlates of intentional recreational GHB use have not well been highlighted. Our study aims to explore GHB's sexual effects, the patterns of choice of sexual partners, the frequency of experienced blackouts, and endured sexual or acquisitory crimes as a result of GHB use.

METHODS

Sixty recreational GHB users filled out a questionnaire on experienced subjective, somatic, and sexual effects of GHB, the frequency of blackouts due to their GHB use, and items on their sexual experiences in relation to GHB use.

RESULTS

Of the sample, 25.9% reported increased sexual arousal as well as more intense attraction towards their sexual partners and increased sexual openness when using GHB; 34.8% had sexual intercourse with strangers, or with others, but not with their partners when using GHB; and 8.6% were victims of acquisitory crimes, whereas 3.4% were victims of a sexual assault. Furthermore, 24.6% typically experienced blackouts when using GHB.

CONCLUSION

Gamma-hydroxybutyrate seems to be a potential substitute for both stimulant and depressant substances. Increased sexual desire and disinhibition may lead to a more frequent and potentially more riskful sexual activity. Experienced blackouts need to be considered as risk factors for suffering sexual or acquisitory crimes.

Bridging the gap between education and appropriate use of benzodiazepines in psychiatric clinical practice

More than half a century after their discovery, benzodiazepines (BDZs) still represent one of the largest and most widely prescribed groups of psychotropic compounds, not only in clinical psychiatry but also in the entire medical field. Over the last two decades, however, there has been an increased focus on the development of antidepressants and antipsychotics on the part of the pharmaceutical industry, clinicians, and researchers, with a reduced interest in BDZs, in spite of their widespread clinical use. As a consequence, many psychiatric residents, medical students, nurses, and other mental health professionals might receive poor academic teaching and training regarding these agents, and have the false impression that BDZs represent an outdated chapter in clinical psychopharmacology. However, recent advances in the field, including findings concerning epidemiology, addiction risk, and drug interactions, as well as the introduction of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition with related diagnostic changes, strongly encourage an updated appraisal of the use of BDZs in clinical practice. During a recent thematic event convened with the aim of approaching this topic in a critical manner, a group of young Italian psychiatrists attempted to highlight possible flaws in current teaching pathways, identify the main clinical pros and cons regarding current use of BDZs in clinical practice, and provide an updated overview of their use across specific clinical areas and patient populations. The main results are presented and discussed in this review.

Care of the adolescent sexual assault victim

Sexual assault is a broad-based term that encompasses a wide range of sexual victimizations including rape. Since the American Academy of Pediatrics published its last policy statement on sexual assault in 2001, additional information and data have emerged about sexual assault and rape in adolescents and the treatment and management of the adolescent who has been a victim of sexual assault. This report provides new information to update physicians and focuses on assessment and care of sexual assault victims in the adolescent population.

Effects of gamma-hydroxybutyric acid and flunitrazepam on ethanol intake in male rats

Both gamma-hydroxybutyric acid (GHB) and flunitrazepam are often used illicitly in combination with ethanol. Nevertheless, the effects that these and other drugs of abuse have on the reinforcing effects of ethanol remain inconclusive. To test the effects of GHB and flunitrazepam on contingent ethanol intake, twelve male Long-Evans rats were trained to orally consume ethanol using a saccharin-fading procedure. After training, all animals preferentially consumed ethanol instead of water at each of five ethanol concentrations (0-32%) when tested with a two-bottle preference test in the homecage. Animals then received a noncontingent dose of ethanol (0.32, 0.56, 1, and 1.33 g/kg), flunitrazepam (0.032, 0.1, and 0.32 mg/kg), or GHB (100, 180, 320, and 560 mg/kg) prior to each subject's daily access to ethanol (18% v/v). Noncontingent doses of ethanol decreased ethanol intake, however, the subjects consumed enough ethanol to maintain a consistent total ethanol dose in g/kg. Flunitrazepam did not affect ethanol intake at any dose tested, whereas GHB only affected intake at the highest dose (560 mg/kg), a dose that also produced sedation. These data suggest that there are perceptible or qualitative differences between GHB, flunitrazepam, and ethanol in terms of their capacity for modulating oral ethanol intake in outbred rats.

Adolescent drug & alcohol use in the 21st century

Screening for drug abuse should be a part of adolescent health maintenance visits. Good interviewing skills using open-ended, nonjudgmental questions in a private setting may elicit a history of drug abuse. A detailed and comprehensive history is important to recognize family dynamics, early behavioral changes (Table 5, see page 198), comorbid psychiatric conditions, and the adolescent's attitude toward substances of abuse. A good physical exam may reveal clinical sequelae of drug abuse. Testing for drug abuse should be done with the patient's consent except in cases where judgment is impaired. Periodic screening for drugs is a part of drug treatment and rehabilitation. The typical pediatrician is not equipped to provide drug counseling and treatment to the abusing adolescent. Specialized referral centers would be ideal, and clinicians need to be aware of local resources in their communities. Anticipatory guidance explaining the ill effects of drugs is mandatory. Prevention should be aimed at increasing public awareness of the consequences of drug abuse, improving parenting techniques, and introducing school-based drug prevention programs. The fight against substance abuse needs to be a community effort in which the individual, the family and the primary care physician play important roles.

Club drugs as causal risk factors for HIV acquisition among men who have sex with men: a review

We reviewed medical and psychology databases for articles published between January 1980 and August 2005 demonstrating associations between HIV/Sexually Transmitted Infection risk and club drug use. Seventy-four articles were reviewed, of which 30 provided adjusted risk ratios for associations between HIV/sexually transmitted infection risk and club drug use among men who have sex with men. Definitions and lists of club drugs were broad and inconsistent. We constructed a conceptual framework of biologically plausible pathways for causation. Using Hill's criteria to examine club drugs as causal risk factors for HIV, we found the most evidence for methamphetamine and volatile nitrites; however, more studies are needed.

Recognition and management of complications of new recreational drug use

Use of illicit drugs in clubs and large dance parties (so-called raves) is a burgeoning cultural trend. Such recreational drug use is associated with several medical complications, both acute and longlasting. Although few, if any, of the drugs currently used in recreational venues are truly new, their patterns and context of use have changed (a great deal in some instances). For some of these substances, this cultural repackaging of the drug experience has resulted in various medical disorders that have previously gone undocumented. This review aims to help treating physicians recognise and manage complications associated with the use of new drugs in clubs, including methylenedioxymethamfetamine, ephedrine, gamma-hydroxybutyrate; gamma-butyrolactone, 1,4-butanediol, flunitrazepam, ketamine, and nitrites. We also alert researchers to specific toxic effects of club-drugs on which more basic information is needed.

Self-injection of flunitrazepam alone and in the context of methadone maintenance in baboons

Patients in methadone maintenance programs use benzodiazepines to "boost" methadone's subjective effects, and flunitrazepam has been prominent in this context. Self-administration of flunitrazepam (0.001-0.32 mg/kg i.v.) alone and during daily oral methadone administration was evaluated in three baboons. Flunitrazepam maintained self-injection as an inverted U-shaped function of dose at rates higher than those maintained by most other benzodiazepines under the same procedure. In the context of demonstrated physical dependence on 3.2 mg/kg/day p.o. methadone, flunitrazepam doses on the ascending limb of the dose-effect curve maintained greater rates of self-injection than before methadone in two baboons. When the methadone dose decreased to 1.8 mg/kg/day, self-injection remained higher for those baboons and became higher than before methadone for the third baboon. Self-injection remained higher when methadone decreased to 1.0 mg/kg/day, except self-injection of the lowest flunitrazepam dose returned to or below the pre-methadone rate for two baboons. After methadone was discontinued, the dose-effect curve shifted to the right in one baboon but remained to the left in two. Flunitrazepam thus served as a reinforcer alone and in the context of methadone maintenance. Lower doses maintained higher self-injection during and shortly after methadone maintenance. Further research should explore the duration of higher self-injection rates following methadone maintenance.

NADPH-cytochrome P-450 reductase is involved in flunitrazepam reductive metabolism in Hep G2 and Hep 3B cells

Flunitrazepam (FNTZ), like other benzodiazepines, has a high affinity for the benzodiazepine receptor within the gama-aminobutyric acid (GABA) complex. These affinities correlate with the pharmacological and therapeutic potencies of the drug. FNTZ is a drug commonly abused by young adults. In humans, FNTZ is oxidized to the major metabolites N-demethylflunitrazepam (DM FNTZ) and 3-hydroxyflunitrazepam (3-OH FNTZ) and reduced to 7-aminoflunitrazepam (7A FNTZ). Human CYP2C19 and CYP3A4 are the principal P-450 cytochromes involved in DM FNTZ and 3-OH FNTZ formation. However, it is not clear which enzyme is responsible for the reduction of FNTZ to 7-aminoflunitrazepam (7A FNTZ). In this study, the involvement of NADPH-cytochrome P-450 reductase in the conversion of FNTZ to 7A FNTZ was investigated in two human hepatoma cell lines, human lymphoblast microsomes specifically expressing human NADPH-cytochrome P-450 reductase and purified recombinant human HADPH-cytochrome P-450 reductase. Significantly more FNTZ was converted to 7A FNTZ in Hep G2 than in Hep 3B cells, and this difference was associated with the catalytic activity and protein levels of NADPH-cytochrome P-450 reductase in these cells. In Hep G2 cells, conversion of FNTZ to 7A FNTZ was effectively inhibited by alpha-lipoic acid, an NADPH-cytochrome P-450 reductase inhibitor. In addition, formation of 7A FNTZ by the microsomal fraction of Hep G2 cells was specifically inhibited by antibody against NADPH-cytochrome P-450 reductase. Under hypoxia (N2 85%; CO2 5%; H2 10%), human lymphoblast microsomes specifically expressing human NADPH-cytochrome P-450 reductase and purified recombinant human NADPH-P-450 reductase catabolized FNTZ to 7A FNTZ in a concentration-dependent manner. These results suggest that NADPH-cytochrome P-450 reductase is involved in the reductive metabolism of FNTZ to 7A FNTZ under hypoxic conditions.

The role of cytochrome P450 2C19 activity in flunitrazepam metabolism in vivo

Flunitrazepam, a hypnotic benzodiazepine, is widely prescribed around the world for the treatment of insomnia and as a preanesthetic. In vitro studies have shown that the metabolism of flunitrazepam to desmethylflunitrazepam and 3-hydroxyflunitrazepam is mediated in part by the polymorphic enzyme CYP2C19. The objective was to examine the role of CYP2C19 activity in determining flunitrazepam kinetics in vivo. Sixteen healthy volunteers (14 genotypic extensive metabolizers and 2 poor metabolizers) were recruited who had a wide range of CYP2C19 activity (0.50-28.8), as determined by the omeprazole/ 5-hydroxyomeprazole ratio (OMR) at 3 hours following administration of omeprazole, 20 mg orally. Each subject received flunitrazepam, 1 mg orally. Blood samples were collected immediately before and up to 48 hours after drug administration and were assayed by HPLC for flunitrazepam and its metabolites, 7-aminoflunitrazepam, desmethylflunitrazepam, and 3-hydroxyflunitrazepam. Spearman correlations were determined for OMR and pharmacokinetic parameters. With increasing OMR (decreasing CYP2C19 activity), the ratio of flunitrazepam to both desmethylflunitrazepam and 3-hydroxyflunitrazepam AUCs increased ( r = 0.55, p = 0.03 and r = 0.65, p = 0.01, respectively). However, variation in CYP2C19 activity did not significantly affect the AUCs of flunitrazepam or its metabolites. The authors conclude that CYP2C19 contributes to the metabolism of flunitrazepam to desmethylflunitrazepam and 3-hydroxyflunitrazepam in vivo, but these data suggest that its role is minor and that differences in CYP2C19 activity do not likely substantially influence its clinical effects.

The flunitrazepam abuse prevention program at a general hospital in Taiwan: a descriptive study

The Bureau of Controlled Drugs at Ministry of Health, Executive Yuan in Taiwan announced, on 1 April 2000, the schedules of controlled drugs with abuse potential and implemented a policy on 1 October 2000 to control them. Flunitrazepam (FM2), along with other two benzodiazepines (triazolam and brotizolam), is placed on Schedule III. The aim of the present study was to analyze the pattern of flunitrazepam prescriptions across all medical subspecialty departments at Taipei Medical University-Wan Fang Hospital (TMU-WFH), Taiwan. We analyzed 1170 prescriptions over 12 month period from 1 July 2000 to 31 May 2001. All prescription data were divided into three 4 month periods: period I was when the flunitrazepam prescription was not controlled, period II represented the time when flunitrazepam was placed on Schedule III and when physicians were required to use a special duplicated prescription form and period III was when the TMU-WFH started to set a stricter control for the prescription of flunitrazepam. The results indicated that the number of flunitrazepam prescriptions during period III had decreased significantly compared with period I (P < or = 0.05). Eventually, 45.7% of flunitrazepam-medicated patients were followed up monthly with a restriction of their flunitrazepam supply to no more than 14 days, 22.9% of patients were followed up fortnightly at clinics with a 14 day supply of flunitrazepam, 15.7% were followed up fortnightly with a 14 day restriction of flunitrazepam plus a non-flunitrazepan benzodiazepine supplement, 10.7% were referred to clinics within the Department of Psychiatry and 5% were switched from flunitrazepam to other drugs.

Buprenorphine prescription by general practitioners in a French region

Since 1996 French general practitioners (GPs) may prescribe sublingual buprenorphine tablets as maintenance treatment for opiate dependence. The computerised data management of the main French health reimbursement system now allows surveillance of the use of this drug, and how it is prescribed. The purpose of this study is to determine the profile of maintained patients, prescribed doses, associated psychotropic treatments and how practitioners prescribe these treatments. This study analyses the 11186 buprenorphine prescriptions electronically transmitted for reimbursement between September and December 1999 in a specific French region. It was found that the 2078 treated patients consumed a mean of 11.5 mg of buprenorphine per day and 12% of them procured prescriptions from more than two prescribers. 43% of maintained patients had an associated benzodiazepine prescription, mainly flunitrazepam, often on the same prescription form. 61% of patients had regular follow-up, others had occasional consultations (21%) and another 18% had deviant maintenance treatment (more than two prescribers or more than 20 mg per day of daily buprenorphine dose). Benzodiazepine consumption was much higher in the 'deviant group' (71.4%). 85% of buprenorphine prescriptions were made by GPs. 21% of GPs prescribed buprenorphine and 61% of those had only one or two maintained patients. Buprenorphine prescription by French GPs is a procedure with no particular requirements, allowing many patients to easily access maintenance treatments. However, a high risk of abuse exists, which demands extensive investigation and evaluation of these practices.

Forensic urinalysis of drug use in cases of alleged sexual assault

The results of 3303 analyses of urine samples, collected in an independent testing programme from individuals who claimed to have been sexually assaulted and believed that drugs were involved, were examined in detail. Of the samples provided, 2026 (61.3%) proved positive for one or more substances. Alcohol, either alone or in combination with other drugs, was by far the commonest substance found, being present in 1358 samples (67.0% of positives). Cannabis was the second most prevalent drug, present in 613 samples, (30.3% of positives). Detailed examination of the testing results does not support the contention that any single drug, apart from alcohol, can be particularly identified as a 'date rape' drug. Rather, the alleged sexual assaults may often take place against a background of licit or recreational alcohol or drug use, where alcohol and other drugs are frequently taken together. The extensive forensic database examined here does not support the concept of a commonly occurring 'date rape' scenario, in which the victim's drink is covertly 'spiked' with a tablet, capsule or powder containing a sedative-hypnotic. This research highlights the need for the early collection of forensic samples in cases of alleged sexual assault. Law enforcement agencies and health professionals should establish guidelines and procedures to ensure that appropriate forensic samples (blood and urine) are collected in a timely manner following allegations of possible drug mediated sexual assault.

Flunitrazepam: an evaluation of use, abuse and toxicity

The benzodiazepine flunitrazepam is extensively prescribed to patients with insomnia in many countries, but has also become popular among alcohol- and drug abusers. Several reports indicate that it is used as a date rape drug and suggest that it may precipitate violent behavior. Furthermore, flunitrazepam is involved in many fatal intoxications in Sweden. This study was designed and conducted to explore the negative consequences of flunitrazepam abuse in Sweden, and to assess the trends in its use and abuse. The occurrence of flunitrazepam in cases referred to the Department of Forensic Chemistry in Linköping, Sweden 1992-1998, was investigated in detail. The detections were studied separately for different groups; medicolegal death investigations, drug abuse cases, driving under influence cases, and other medicolegal cases. These data were further compared with the sales, and seizures by the Swedish Customs and the Swedish Police. During 1992-1998, 641 fatalities occurred, where the cause of death was attributed to intoxication with flunitrazepam solely (130) or in combination with other drugs, or concomitant conditions (511). In 78% of all driving under influence cases, where flunitrazepam was detected, the analyses also disclosed the presence of illicit drugs. A similar association was seen in drug abuse cases. The seizures reported by the Swedish Customs revealed a substantial and increasing illegal trade. Cases, where flunitrazepam seemingly induced violent behavior were identified, and one of these is described in some detail. It is concluded that the abuse pattern and the toxicity of flunitrazepam should be kept in mind by forensic investigators and that this panorama also should be considered when decisions about the registration and classification of flunitrazepam are made in different countries.

Flunitrazepam abuse and personality characteristics in male forensic psychiatric patients

Sixty male non-psychotic forensic psychiatric patients (aged 16-35 years) were studied after they completed their ordinary forensic psychiatric assessment (FPA). The prevalence of flunitrazepam (FZ) abuse was investigated by using both structured and in-depth interviews with the objective of studying the relationship between the abuse and personality traits. The patient's characteristics, DSM-IV disorders, and actual sentences were obtained by studying their files. In order to obtain measures on their personality traits, self-report inventories were administered to the patients. Eighteen out of 60 patients were FZ abusers, but only 4 of them received a diagnosis related to the FZ abuse during the ordinary FPA. In almost all cases, however, indications of the FZ abuse were found in the files. No differences in personality traits were found between the groups. The frequency of previous admissions to an FPA and actual sentences of robbery, weapons offenses, narcotic-related offenses, and other crimes (such as theft) among the FZ abusers deviated significantly from forensic non-FZ abusers. Therefore, the FZ abuse per se might be more responsible for their tendency to commit crimes characterized by danger and thrill-seeking (such as robbery, weapons offences, and theft) than personality. The most important conclusion is that assessment of FZ abuse is needed in forensic psychiatry.

Care of the adolescent sexual assault victim

Sexual assault is a broad-based term that encompasses a wide range of sexual victimizations, including rape. Since the American Academy of Pediatrics published its last policy statement on this topic in 1994, additional information and data have emerged about sexual assault and rape in adolescents, the adolescent's perception of sexual assault, and the treatment and management of the adolescent who has been a victim of sexual assault. This new information mandates an updated knowledge base for pediatricians who care for adolescent patients. This statement provides that update, focusing on sexual assault and rape in the adolescent population.

Recent evolution in opiate dependence in France during generalisation of maintenance treatments

Two maintenance drugs had been used in France since 1996, methadone and high-dosage buprenorphine. This study aimed to examine changes in drug use from observations gathered between 1995 and 1997, within the framework of the French program for the monitoring of drug dependence (OPPIDUM). This annual survey studies psychoactive substances consumed by drug addicts attending specialised drug care centres. During the last three surveys, 16 centres collected a total of 1597 patient-files. This study shows an increase in the number of patients undergoing maintenance treatment (from 14 to 69%), a reduction in the number of intravenous drug users (from 55 to 22%) and a reduction in consumption of psychoactive substances. However, poly-drug addiction behaviour continues and high-dose buprenorphine subjects frequently use the substance intravenously and in association with benzodiazepines.

Misleading results of ethanol analysis in urine specimens from rape victims suffering from diabetes

We report appreciably high concentrations of ethanol (82 and 102 mg/dL) in specimens of urine collected from two victims of date rape. Both girls (aged 15 and 18 years) suffered from diabetes mellitus, but adamantly denied drinking any alcohol before or after the incident. The presence of glycosuria and high risk of fungal infections in female diabetics suggests that ethanol was produced in vitro by fermentation after voiding. Making a routine test for sugar in the urine and ensuring that the sampling tubes contain sufficient sodium or potassium fluoride to inhibit glycolysis are recommended practices. A specific marker for post-sampling synthesis of ethanol might also be used such as the 5HTOL/5HIAA ratio.

Flunitrazepam: more than a date rape drug

STUDY OBJECTIVE

To evaluate the independent relationship between depressive symptoms. self-esteem. and drug resistance self-efficacy, and future intentions to use flunitrazepam.

DESIGN

Cross-sectional survey.

SETTING

Community-based family planning clinics.

PARTICIPANTS

865 sexually active women who self-identified as Caucasian. African-American. or Mexican American. denied using flunitrazepam in the last 12 months and reported intentions to use or not use this substance in the next 12 months.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

An anonymous self-report measure assessed the patient's intentions to use flunitrazepam in the next 12 months: other lifetime drug use: and standardized measures of depression. self-esteem, and drug resistance self-efficacy. We hypothesized that future potential users of flunitrazepam would exhibit an increased number of depressive symptoms, lowered self-esteem, and limited drug resistance self-efficacy.

RESULTS

Of the 865 subjects. 16 (1.8%) reported using flunitrazepam in their lifetime but not in the last 12 months. and 46 (5.3%) were identified as potential users. Logistic regression analyses controlling for confounding factors found that potential to use flunitrazepam was significantly associated with limited drug resistance self-efficacy (adjusted odds ratio [AOR] = 9.3) and the presence of both severe depressive symptoms and lowered self-esteem (AOR = 3.2).

CONCLUSIONS

These data suggest that young women with severe depressive symptoms and diminished self-esteem are at high risk for future flunitrazepam use and may use this drug to self-medicate psychological distress.

Prevalence, patterns, and correlates of voluntary flunitrazepam Use

OBJECTIVE

To determine prevalence, patterns, and correlates of voluntary flunitrazepam use in a sample of sexually active adolescent and young adult women 14 to 26 years of age.

DESIGN

Cross-sectional survey.

SETTING

University-based ambulatory reproductive health clinics.

PATIENTS OR OTHER PARTICIPANTS

There were 904 women self-identified as white, African-American, or Mexican-American.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Lifetime, frequency, patterns, and physical effects of flunitrazepam use.

RESULTS

Lifetime use was reported by 5.9% (n = 53) of subjects, with frequency of use ranging from 1 to 40 times. Flunitrazepam was taken most often with alcohol (74%), and 49% took this substance with other illicit drugs. Logistic regression analyses controlling for age and race/ethnicity found that users were significantly more likely than were nonusers to report lifetime use of marijuana (odds ratio [OR] = 3.6) or LSD (OR = 5.2), having a peer or partner who used flunitrazepam (OR = 21.7), pressure to use flunitrazepam when out with friends (OR = 2.7), and a mother who had at least a high school education (OR = 2.6). Finally, 10% of voluntary users reported experiencing subsequent physical or sexual victimization.

CONCLUSIONS

Voluntary use of flunitrazepam is becoming a health concern to sexually active young women who reside in the southwestern United States. Young women who have used LSD or marijuana in the past or who have a peer or partner who used this drug appear to be at the greatest risk.