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This volume contains a long introduction by the editor and 13 parts of the Reports. Steve Sheppard Indianapolis: Liberty Fund, Learn more View in context. Selected Writings of Sir Edward Coke, vol. Copyright The copyright to this edition, in both print and electronic forms, is held by Liberty Fund, Inc. Category: United Kingdom and Ireland.

Knock-Out Drugs: Their Prevalence, Modes of Action, and Means of Detection

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Official websites use. Share sensitive information only on official, secure websites. 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. 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. The most frequently used drug in cases of sexual assault is still alcohol ca. The presence of involuntarily consumed medications and drugs of abuse is demonstrated by routine toxicological analysis only in relatively few cases ca. 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. 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. Keywords: sex crimes, gamma-aminobutyric acid abuse, hair analysis, drug screening, benzodiazepine. Press reports of the use of knock-out drugs to facilitate crimes have become more common in recent years, beginning in the USA, but now more commonly in Europe as well. Some years ago, the best-known cases in Germany involved robbery and other crimes against property: the public is familiar with reports of alcohol-intoxicated customers in St. Pauli the Hamburg nightlife district , or in a traditional Munich establishment, being sedated with Noludar methylprylone for this purpose. Today, however, most of the crimes committed in association with knock-out drugs are of a sexual nature, occurring in the setting of the disco and rave scene 1 — 5. Three illustrative cases are presented in the Internet supplement see case illustrations. A year-old bar owner fell into conversation before closing time with his last remaining customers, two women aged 23 and 25, who told him they had missed the last bus home. He invited both of them to stay in his apartment overnight. They accompanied him there, buying two bottles of champagne in a gas station along the way. Once at his apartment, the three drank champagne together. The bar owner had no recollection of what happened after that. When he woke up naked in bed the next morning, he found that the two women had disappeared, and all objects of value had been removed from the apartment. Out of embarrassment, he waited till evening to report the incident to the police, whereupon blood and urine samples were taken. He was unable to give any more than a vague description of the two women. Video surveillance pictures from the gas station enabled the police to identify the two women. They stated that he had had sexual intercourse with one of them after taking the drink, but he himself could not remember whether this had been the case. The women stated that he had fallen into a deep sleep afterward, and they had exploited his condition by searching the apartment and removing valuables from it. A young man pretending to be carrying out a study of 'alco-pops' carbonated alcoholic beverages and clothing on behalf of a consumer protection organization told potential volunteers that they would receive a monetary reward for participating. A year-old woman was induced in this way to try out several drinks. She later said that one of these, an orange-colored mixed drink, had tasted very bitter. While undressing in order to try out various pieces of clothing, as required for the 'study,' she was secretly filmed by the suspect. After consuming a further orange-colored drink, she suddenly felt strange and lost consciousness, and she could not remember anything that happened afterward. She was at first unarousable and incapable of walking. This could not be explained by alcohol consumption alone, as she stated that she could ordinarily tolerate the amount of alcohol that she had consumed. No chemical toxicological studies were performed to detect knock-out drugs in this case, because the police learned of this incident only later, during a separate investigation. She later stated that she had suddenly felt strange, her memory had become vague, and she had no longer felt capable of acting according to her own will. She had then engaged in a sexual act with the suspect in a lavatory. The next day, the victim complained of nausea, palpitations, and tachycardia. Chemical toxicological analyses of blood and urine samples taken 39 hours after the incident were negative. Her calculated presumed blood alcohol concentration at the time of the incident, based on the amount of alcohol she said she had drunk, did not explain the condition she reported having been in at the time. A hair specimen was obtained 8 weeks after the incident: diphenhydramine was found in the proximal 3 cm of hair, in a concentration of 1. This finding can be summarized as follows: the alleged incident was within the time period during which the hair specimen had grown. It should also be considered whether the patient was taking any other medications that might explain the finding. The long temporal interval that results between the incident and the obtaining of blood and urine specimens often makes the administered substances impossible to detect by chemical toxicological analysis. A further hindrance to laboratory detection is the fact that knock-out drugs are usually given in the smallest possible dose that will sedate the victim; also, knowledgeable criminals often choose to use substances that are rapidly eliminated, so that they will not be detected. Volatile substances such as chloroform, ether, and halothane were formerly used more commonly to facilitate crime 6. The spectrum of administered substances has become much wider in recent years. The commonly mentioned substance gamma-hydroxybutyric acid GHB , also known as Liquid Ecstasy, can only be analytically detected in a very narrow temporal window 8 hours in the blood, 12 hours in urine. The term 'drug-facilitated sexual assault' DFSA has now become the standard international designation of this type of crime. Criminals use drugs to facilitate sexual assault with the intention of producing the following effects:. On the other hand, in the context of sex crimes, drugs are sometimes also given with the intention of increasing sexual desire and lowering behavioral inhibitions amphetamines, cocaine. On the basis of a selective literature search using the terms 'drug-facilitated sexual assaults' DFSA and 'drug-facilitated crimes' DFC , the authors here present the mechanisms of action and windows of detectability of the substances most commonly used as knock-out drugs, so that medical colleagues involved in such cases will be better able to obtain adequate samples for chemical toxicological analyses. According to reports mainly originating in the USA, the incidence of drug-facilitated sexual assault seems to have risen markedly in recent years, although precise epidemiological data are lacking because of the naturally large number of cases that are not made known to the authorities. Many drugs of the types used for such crimes are taken voluntarily, and the covert administration of a drug can only rarely be proved 7 , 8. The Munich department of forensic medicine registered a total of 92 cases from to in which the administration of a knock-out drug was suspected 3. The crimes that were committed thereafter consisted mainly of robbery The Bonn department of forensic medicine registered a tenfold increase in the number of investigations of possible intoxicating substances in sex crimes from to , currently reaching 40 to 50 cases per year 5. Chemical toxicological studies are generally carried out both in victims and in criminal suspects. Criminal prosecution often had to be terminated because no suspect was identified, the suspect could not be apprehended, or there was insufficient evidence to convict e-box. Modified from 10 GHB, gamma-hydroxybutyric acid. Victims of the administration of knock-out drugs often describe the following symptoms, depending on the pharmacodynamics of the substances used 11 :. All of these symptoms should be asked about when the medical history is taken box 1. Possible aftereffects - nausea, vomiting, dizziness, symptoms referable to the heart, muscle weakness? Temporal interval before reporting to police, seeking medical attention, giving blood and urine specimens? Amnesia is mainly present when GHB and benzodiazepines have been used; in particular, 1,4-benzodiazepines like flunitrazepam are more likely to cause amnesia than 1,5-benzodiazepines like clobazam Amnesia can also be present where there has not been any loss of consciousness. Midazolam can lead to the generation of fantasies of a sexual nature. During physical examination, special attention should be paid to injuries, particularly injuries of an apparently sexual nature such as bruises on the medial surface of the thighs or scratches on the breasts, as well as apparently trivial injuries. Furthermore, specimens should be obtained for molecular-biological and toxicological analysis box 2. Securing of specimens for toxicological analysis bodily fluids should always be stored at cool temperatures; if serum and urine are to be stored for longer times, they should be frozen. When the obtaining of a hair specimen is indicated, a lock of hair about the thickness of a pencil should be taken and marked at the scalp end with a string; if hair from the head is not available, pubic hair can be taken instead. Hair specimens should be taken about 4 weeks after the incident if the findings in blood and urine are negative and should be stored under dry and dark conditions at room temperature. Here, we can give no more than a brief outline of the agents and groups of agents that are most commonly in question as potential knock-out drugs; further information is found in Musshoff and Madea An extended list of potential knock-out drugs is also found in the e-table. Substances belonging to this large group are used therapeutically as tranquilizers, anticonvulsants, hypnotics, and sedatives. For each type of benzodiazepine, however, the law specifies a threshold quantity below which the specifications for the prescribing of narcotics do not apply. Benzodiazepines can cause amnesia when taken in combination with alcohol or opioids. Flunitrazepam, in particular, has the reputation of being a 'date-rape' drug. As a result, the manufacturer changed the composition of the tablet in so that it has a bluish color, discolors drinks to which it is added, precipitates in solution, and tastes slightly bitter. Tablets of the older type are still available in some countries, however, and they are still often sold by generic drug manufacturers and other companies. Zopiclone, zolpidem, and zaleplone are members of the latest generation of non-benzodiazepine hypnotic agents. They have anxiolytic, sleep-promoting, and muscle-relaxing effects. They are suitable for use as knock-out drugs especially because of the rapid onset of their effect within 10 to 30 minutes , but also because they induce amnesia and can only be detected for a short time short half-life. In medicine, gamma-hydroxybutyric acid is now only rarely used as an intravenous anesthetic agent. It has also been approved for the symptomatic treatment of narcolepsy It is available on the black market as a hygroscopic solid or as a colorless or colored liquid aqueous solution of GHB salts. At low doses ca. When taken in higher doses up to 2. At still higher doses, it is heavily sleep-inducing. Overdoses can cause a sudden, deep sleep from which the affected person can hardly be aroused. GHB overdoses, i. It is dangerous to combine GHB with alcohol, respiratory depressant drugs, or benzodiazepines. Nausea and vomiting may occur, and this, in combination with the narcotic effect of the drug, can lead to death by aspiration of vomitus and suffocation. Moreover, life-threatening respiratory depression and cardiac arrhythmias may arise. Because GHB shares its sleep-inducing property with a number of other substances, the correct diagnosis of GHB intoxication is often missed by emergency medical personnel and other persons trying to help. A benzodiazepine or opioid overdose is usually suspected at first, but neither flumazenil nor naloxone is an effective antidote to GHB. The possible reversibility of the effects of GHB with physostigmine is currently a matter of debate Butyro-1,4-lactone, also called gamma-butyrolactone GBL , is a colorless liquid with a faint intrinsic odor. It is widely used as an industrial solvent and as a paint remover, graffiti remover, nail-polish remover, and cleaning agent. It is also used as a reagent for the manufacture of pharmaceuticals and agricultural chemicals. Unlike GHB, it has not yet been classified as an illegal narcotic agent, even though it is used as a knock-out drug. It is hydrolyzed to GHB in the body through the action of 1,4-lactonase. BDO, too, is metabolized in the body to GHB through the action of an alcohol dehydrogenase and an aldehyde dehydrogenase. It can thus be used as an alternative recreational or knock-out drug. Its effect begins about 5 to 20 minutes after it is taken by mouth and lasts about 2 to 3 hours. Doses above 4 mL have a sleep-promoting effect, like GHB. Ketamine is sold as a generic drug in Germany. It requires a prescription, but is not subject to the provisions of the Law on Narcotics. It is used for general anesthesia in anesthesiology as well as for analgesia and the treatment of otherwise intractable status asthmaticus, and furthermore as a hypnotic agent. It is used as a drug of intoxication and a party drug because of its dissociating, consciousness-altering effect. Its use as a knock-out drug has also been described. Scopolamine, hyoscine, and atropine from the belladonna family are the more important members of this class. Scopolamine is mildly calming at a low dose, with an inhibitory effect on the vomiting center in the brain; at higher doses, it has a blunting effect, producing apathy. Some first-generation H 1 antihistamines, in particular, have an antagonistic effect on. Most of these agents also readily enter the central nervous system and are thus used, for example, as antiemetics in sea-sickness and as sleep-promoting medications. First-generation H 1 antihistamines are suitable for use as knock-out drugs because of their anticholinergic effects and, not least, because of their ready availability. The use of diphenhydramine and doxylamine for this purpose has been described. Many other substances, such as the muscle relaxants carisoprodol and cyclobenzaprine, have been used as knock-out drugs because of their sedating effects. The same is true of volatile substances including ether, chloroform, and laughing gas nitrous oxide. Because these agents are rapidly eliminated or breathed off, however, they are detectable in the body for no more than a very short time. Specimens must be secured in airtight, closed containers to prevent any further loss of the substance in question before the specimen can be analyzed. Special tests are necessary to detect these substances, e. Today, volatile substances are used in the party scene as 'poppers'—these generally include amyl nitrite, butyl nitrite, isobutyl nitrite, and combinations of these three substances. They have a pronounced vasodilating effect. Five to 15 seconds after they are inhaled, mental effects set in, including an intensification of perception, which may persist for about 10 minutes depending on the dose. Because of their short-lived effect, 'poppers' are relatively unsuitable as knock-our drugs; they are taken for also short-lived sexual stimulation, as an aphrodisiac. Stimulants such as cocaine, amphetamine, and ecstasy are also being more commonly used in cases of drug-facilitated sexual assault. Most of the substances discussed above can be detected in the blood for several up to 24 hours, and in the urine including metabolites for a few days. A special feature of GHB is that it is very rapidly resorbed, reaching its peak plasma concentration in 20 to 45 minutes. Its half-life is circa 30 minutes. It can be detected in the blood for 8 hours and in urine for up to 12 hours 15 , Because of the brief time available for the detection of these substances in the blood and urine, the frequent long delays between the incident and its reporting to the police or a physician, and the fact that a low dose of a knock-out substance often suffices to impair consciousness in a person who has already consumed alcohol and other drugs, both blood and urine must often be obtained for chemical toxicological analysis, depending on the particulars of the case. The material should always be stored at a low temperature, because bacterial activity might otherwise raise the concentration of the substance in question, especially in the case of GHB. For screening tests, mL of urine should be obtained as soon as possible, no later than 2 to 4 days after the incident. At least 10 mL of citrate-free blood should also be obtained as soon as possible, optimally no more than 24 hours after the incident. If a longer time has elapsed between the incident and the medical examination, or if the chemical-toxicological studies of blood and urine are negative despite a well-grounded suspicion that knock-out drugs were administered, then the analysis of a hair sample can be considered. The sample should be obtained about 4 weeks after the incident. Hair grows an average of 1 cm per month; thus, the demonstration that a substance is present in a proximal hair segment but not more distally implies that it was ingested at a time near the incident. Many potential knock-out drugs can later be detected in hair samples even if they were only consumed once 17 — The detection of GHB, however, is problematic, because the analysis must be capable of distinguishing the normal, endogenous concentration of this substance from the perhaps no more than slightly elevated concentration in a neighboring segment, resulting from exogenous administration 20 , It must be pointed out that conventional testing laboratories are generally unable to cover the entire spectrum of required analyses, or to perform them with the necessary sensitivity 22 — Thus, only specialized laboratories should be involved; the laboratory can also give helpful advice in individual cases. This is particularly true with respect to hair analyses after the consumption of a single dose of a foreign substance. The possible judicial consequences of the use of a knock-out drug in Germany come under the following headings in the German criminal code Strafgesetzbuch, StGB :. Even in the absence of robust epidemiological data on the frequency of drug-associated sex crimes, the number of investigations for such crimes, e. Proof of the administration of knock-out drugs is often difficult because the victim can no longer recall the event after a shorter or longer phase of unconsciousness or antegrade amnesia and is therefore delayed in seeking a doctor or informing the police. The most commonly detected substance in sex crimes is still alcohol ca. Routine tests only rarely detect involuntarily consumed medications and drugs in ca. When the administration of knock-out drugs is suspected, a mL urine sample should be obtained as soon as possible for screening, and at least 10 mL of citrate-free blood should also be obtained as soon as possible, optimally within 24 hours. Meticulous medical history-taking, physical examination, and obtaining of specimens are prerequisites for the successful detection of cases of this type. The authors declare that they have no conflict of interest as defined by the guidelines of the International Committee of Medical Journal Editors. As a library, NLM provides access to scientific literature. Dtsch Arztebl Int. Find articles by Burkhard Madea. PMC Copyright notice. Open in a new tab. Dose oral Effect 1. Conflict of interest statement The authors declare that they have no conflict of interest as defined by the guidelines of the International Committee of Medical Journal Editors. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel.

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