Michelle Muscat MD MRCS(Ed) MSc, PG Dip, FRCPath, PhD

Flunitrazepam or ‘rohypnol’ is best known as a date rape drug or “roofie”(1). It is a benzodiazepine with strong sedative and hypnotic effects. It is also associated with amnesic effects (2), sleep alterations (3) and has been used in the treatment of insomnia. Paradoxical effects such as confusion, agitation and aggression have also been reported, together with risky decision making (4-6). In the past the drug had been used for anaesthetic purposes (7, 8)

Its use in the facilitation of sexual assault makes both its clinical and forensic toxicological profiles extremely pertinent (9, 10). Some instances have been associated with leaving an unattended drink. The concerns led even to the trials of portable Raman spectrometers to detect spiked drinks (11) in addition  to existing and emerging laboratory confirmation methods (12-15). Fluorescence spectroscopy has also been proposed to screen colourless drinks (16). Flunitrazepam has been associated with medicolegal cases (17) and even forensic psychiatry in relation to dangerous activities, crime propensity (18) and criminal lifestyle associations (19) of the drug.

Other reported effects include skin necrosis (20). A recent case report described gastric fluid that was bright blue after flunitrazepam overdose (21). A case report described intra-arterial injection of flunitrazepam together with methadone, water and saliva resulting in compartment syndrome (22). Fluctuations in blood pressure between night-time and morning have been documented with chronic flunitrazepam use (23). These are some illustrative examples, other instances were reported of other effects alone or in combination with other drugs.

References

 

  1. Waltzman ML. Flunitrazepam: a review of “roofies”. Pediatric emergency care. 1999;15(1):59-60.
  2. Galizio M, Mathews M, Mason M, Panoz-Brown D, Prichard A, Soto P. Amnestic drugs in the odor span task: Effects of flunitrazepam, zolpidem and scopolamine. Neurobiology of learning and memory. 2017;145:67-74.
  3. Misaki K, Nakagawa H, Koshino Y, Kishi H, Ota T, Okuda K, et al. Effect of flunitrazepam on sleep and memory. Psychiatry and clinical neurosciences. 1998;52(3):327-32.
  4. Bramness JG, Skurtveit S, Morland J. Flunitrazepam: psychomotor impairment, agitation and paradoxical reactions. Forensic science international. 2006;159(2-3):83-91.
  5. Eschallier A, Leblanc A, Debruyne D, Fialip J, Lavarenne J. [Drug dependence with paradoxical effects of flunitrazepam. Apropos of a case study]. Journal de toxicologie clinique et experimentale. 1987;7(4):281-4.
  6. Lane SD, Cherek DR, Nouvion SO. Modulation of human risky decision making by flunitrazepam. Psychopharmacology. 2008;196(2):177-88.
  7. Dundee JW, George KA, Vardarajan CR, Clarke RS, Nair SK. Proceedings: Anaesthesia and amnesia with flunitrazepam. British journal of anaesthesia. 1976;48(3):266.
  8. Freuchen I, Ostergaard J, Mikkelsen BO. Anaesthesia with flunitrazepam and ketamine. British journal of anaesthesia. 1981;53(8):827-30.
  9. Dinis-Oliveira RJ. Metabolic Profile of Flunitrazepam: Clinical and Forensic Toxicological Aspects. Drug metabolism letters. 2017;11(1):14-20.
  10. Ohshima T. A case of drug-facilitated sexual assault by the use of flunitrazepam. Journal of clinical forensic medicine. 2006;13(1):44-5.
  11. Ali EM, Edwards HG. The detection of flunitrazepam in beverages using portable Raman spectroscopy. Drug testing and analysis. 2017;9(2):256-9.
  12. Mullins ME. Laboratory confirmation of flunitrazepam in alleged cases of date rape. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 1999;6(9):966-8.
  13. Kiss B, Bogdan C, Pop A, Loghin F. A rapid UPLC-MS/MS method for simultaneous determination of flunitrazepam, 7-aminoflunitrazepam, methadone and EDDP in human, rat and rabbit plasma. Talanta. 2012;99:649-59.
  14. Marchi I, Schappler J, Veuthey JL, Rudaz S. Development and validation of a liquid chromatography-atmospheric pressure photoionization-mass spectrometry method for the quantification of alprazolam, flunitrazepam, and their main metabolites in haemolysed blood. Journal of chromatography B, Analytical technologies in the biomedical and life sciences. 2009;877(23):2275-83.
  15. Lee HH, Lee JF, Lin SY, Lin YY, Wu CF, Wu MT, et al. Simultaneous quantification of urine flunitrazepam, nimetazepam and nitrazepam by using liquid chromatography tandem mass spectrometry. Clinica chimica acta; international journal of clinical chemistry. 2013;420:134-9.
  16. Leesakul N, Pongampai S, Kanatharana P, Sudkeaw P, Tantirungrotechai Y, Buranachai C. A new screening method for flunitrazepam in vodka and tequila by fluorescence spectroscopy. Luminescence : the journal of biological and chemical luminescence. 2013;28(1):76-83.
  17. Druid H, Holmgren P, Ahlner J. Flunitrazepam: an evaluation of use, abuse and toxicity. Forensic science international. 2001;122(2-3):136-41.
  18. Daderman AM, Edman G. Flunitrazepam abuse and personality characteristics in male forensic psychiatric patients. Psychiatry research. 2001;103(1):27-42.
  19. Daderman AM, Edman G, Meurling AW, Levander S, Kristiansson M. Flunitrazepam intake in male offenders. Nordic journal of psychiatry. 2012;66(2):131-40.
  20. Menni S, Boccardi D, Coggi A. Skin necrosis caused by flunitrazepam abuse. Acta dermato-venereologica. 1999;79(2):171.
  21. Yamagishi T, Akashi A, Shimizu H, Ishida T, Tanabe T, Sugiyama K, et al. Flunitrazepam overdose induces brilliant-blue gastric fluid. Acute medicine & surgery. 2018;5(2):202-3.
  22. Kamphuis SJM, Jandali AR, Jung FJ, Sproedt J. [Compartment syndrome of the forearm after intra-arterial self-injection : With a mixture of methadone, flunitrazepam, saliva and water]. Der Unfallchirurg. 2018;121(8):669-73.
  23. Bosone D, Fogari R, Zoppi A, D’Angelo A, Ghiotto N, Perini G, et al. Effect of flunitrazepam as an oral hypnotic on 24-hour blood pressure in healthy volunteers. European journal of clinical pharmacology. 2018;74(8):995-1000.