Drug Facilitated Sexual Assault Can toxicological screening prove it

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Drug Facilitated Sexual Assault -Can
toxicological screening prove it?

• Dr John Lewis
• Toxicology Unit
• Pacific Laboratory Medicine Services
• Northern Sydney Health

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• Past routine toxicological screening using
  comprehensive toxicological techniques has failed
  to detect any drugs

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Some Questions for the lab

• Were drugs used at all?
• What were we testing for?
• Were these tests adequate?
• Are there drugs we dont test for?
• Are there drugs we cant test for?
• Time frame from assault to examination?

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• Could they be using a drug that is no longer
  available?
• Veterinary products?

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What drugs are likely to be given?

• Alcohol
• CNS depressants
• Drugs exhibiting disinhibition, memory loss,
  dissociation
• MDMA

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• In 2002, in 10 cases of alleged drug-facilitated
  sexual assault, we performed a number of targeted
  analyses in addition to the existing routine
  profile.

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• All victims claimed their drinks had been spiked.
• Total memory loss was a common symptom.
• Majority of victims did not present for treatment
  until 12-24 hrs after assault.

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• Most common symptom in alleged drug facilitated
  sexual assault (DFSA) is anterograde amnesia
• The victim remembers events up to but not after
  the drink

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Routine analysis included

• Screening tests for amphetamine, cocaine,
  benzodiazepines, cannabis, opiates and alcohol.
• Broad spectrum screening for a wide range of
  therapeutic and illicit drugs.
• Mass spectrometry

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Additional Targeted Analyses

• Benzodiazepines by GC/MS - SIM (LOD 5ng/ml)
• Ketamine by GC/MS - SIM (LOD 50ng/mL)
• GHB by GC/MS - SIM (LOD 5ug/mL)
• Propofol by GC/MS - SIM (LOD 50ng/mL)
• Chloral Hydrate by GC - EC (LOD 80ng/mL)

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Benzodiazepines

• Most common - Temazepam (Normison) and
  Flunitrazepam (Rohypnol).
• Temazepam can be identified in urine for several
  days following a single dose.
• Flunitrazepam can be identified for at least 24
  hours following a 1 mg ingestion (2mg tablets).

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Was our technology adequate?
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Patient receiving Ketamine
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• However, we do not know how little Ketamine may
  be given to a victim and whether existing
  technology could identify it in a random urine 24
  hours later

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• Importantly, scientific publications and
  textbooks on drug-facilitated sexual assault
  contain no information on likely dose or urine
  levels.

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On Ketamine

• Moore et al J. Anal. Toxicol (2001) 25 583-587
• Reported urine levels of Ketamine and its
  metabolites in 33 subjects who had
  self-administered the drug

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Ketamine Levels

• Estimated time range 3-36 hrs after use
• Dose unknown
• Urine levels 6-8000 ng/mL
• Route of administration unknown

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• It would not be unreasonable to conclude that if
• Ketamine were to be administered to a potential
  victim, especially with alcohol, then the dose
  would be very low.
• And our routine detection limits are not low
  enough.

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Detecting GHB
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Finding useful objective data

• Forensic urinalysis of drug use in cases of
  alleged sexual assault. Journal of Clinical
  Forensic Medicine (2001) 8. 197-205
• Hindmarsh, I., ElSohly, M., Gambles, J. and
  Salamone, S.

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• Despite ongoing international media interest in
  the subject and the naming of a number of
  specific psychotropic substances (among them GHB,
  flunitrazepam, ketamine and zopiclone, little
  objective evidence has been available..

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• Unfortunately, the researchers were unable to
  determine exact time intervals between alleged
  assault and specimen collection

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Elimination of GHB

• GHB exhibits zero-order kinetics - it has no
  half-life.
• Time required to eliminate half a given dose
  increases as the dose increases.

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GHB
5hr Urine from Subject taking GHB
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GHB??
10hr Urine from subject taking GHB
Ion ratios wrong
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TYPICAL BLANK URINE FROM LAB STAFF
SUBJECT TOOK GHB 10HR URINE
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BLANKS MATCH 10HR SAMPLE
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• Everyone excretes GHB - it is a normal urinary
  metabolite. Concentrations lt 10 ug/mL may be
  considered normal.

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GHB Overdose

• A patient presented at the emergency department
  of a North Coast hospital. He had organised a
  Rave Party at his home and had been drinking
  throughout the night.
• He was taken unconscious to AE at 0600. A
  urine was collected at 0800.
• He claimed someone had spiked his drink.

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GHB DETECTED IN URINE SPIKED DRINK
UURINE COLLECTED lt6 HRS AFTER INGESTION
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Results

• No drugs were identified in 8/10 cases
• Drugs were detected in only 2/10 cases
• 1 Temazepam _at_ 80 ng/mL
• 2 Methylamphetamine (460 ng/mL MDMA 100 ng/mL)

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• Alcohol was detected in 6/10 cases

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Alcohol - No useful information

• If urine test is ve, merely supports admission
  that victim had a couple of drinks some hours
  ago.
• More than likely urine test is -ve.
• One standard alcoholic drink is metabolised per
  hour. Only a fraction appears unmetabolised in
  urine. After some hours its all gone.

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• It may be that sexual assault victims have been
  given alcohol fortified with more alcohol.

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However more recently
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Ketamine detected in sexual assault victim
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What we dont know

• The victim had other recreational drugs in her
  urine.
• Had she taken them herself?

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Conclusions - Benzodiazepines

• We concur with other workers that commonly
  implicated benzodiazepines such as Temazepam and
  Flunitrazepam can be readily identified in urine
  for at least 24 hours, following a single low
  dose. Thus it is unlikely they are commonly used
  to facilitate sexual assault.

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Conclusions - GHB

• There is anecdotal evidence for the use of GHB in
  drug-facilitated sexual assault.
• However, because of its dose-dependent half-life,
  it may or may not be detected unless specimens
  are collected within a few hours of ingestion.

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Conclusions - other drugs

• We have no evidence of other drugs implicated in
  drug-facilitated sexual assault.
• Without such evidence more targeted analyses are
  unwarranted and unsustainable.

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Conclusions - Ketamine

• Ketamine, and its metabolites, can be identified
  in urine following therapeutic or overdose
  amounts.
• However, low doses that may be used in
  drug-facilitated sexual assault may go
  undetected.

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Where we are up to

• We have very sensitive methods for Ketamine,
  GHB and the potent benzodiazepines

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In Summary

• There are many drugs that could be used in DFSA.
  People suspect Benzos, GHB, Ketamine, LSD
  -------------gtgt The list goes on.
• Since this investigation began, our technology
  has improved significantly.
• However, in many of these cases the drug was not
  or is no longer there.