T he use of alcohol and sedat ing subs tances by rapists is a centuries-old practice. Today numer-

ous legal and illegal drugs can be misused to sedate people involuntarily. Because these drugs can be covertly added to beverages in a social setting, sub- s tance- induced rape poses unique difficulties for health professionals, law enforcement officials, and rape crisis counselors, as well as rape survivors and those trying to reduce their risk of assault.

Many sedat ing subs tances can be misused and cause similar symptoms; combined with alcohol, their effects are magnified. The inability of the rape sur- vivor to remember the details of the event as a result of the sedat ing effects he ightens the difficulty in gather- ing information that could help prosecute the rapist. Drug tests are now available that may help in collect- ing evidence and identifying the subs tances that were used. And a new federal law, the Drug-Induced Rape Prevention and Punishment Act of 1996, sets prison terms of up to 20 years for anyone convicted of using any controlled subs tance with the intent to commit a violent crime, including sexual assault.

Availability of drug testing Hospital ED personnel should collect evidence , including urine samples that Wfli[~be~ submit ted for testing, according to strict c h a i n - o f [ c ~ o d y proce-

,, ~ f ,

dures, which will be critical if the case is prosecuted. Even if the rape survivor chooses not to report the incident to law enforcement authorities, drug tes t ing can be important to identify subs tances used.

A free drug tes t ing service has been made avail- able to hospital emergency departments , rape crisis centers, and law enforcement agencies by Hoffmann- La Roche (Figure 1). Roche ini t iated the program be- cause of concern about reports tha t one of its

Robert Armstrong, is vice president, Medical Affairs, Roche Laboratories, Nutley, New Jersey. J Emerg Nurs 1997;23:378-81. Copyright © 1997 by the Emergency Nurses Association. 0099-1767/97 $5.00 + 0 18/1/83721

Legal and illegal drugs can be m i s u s e d to s eda te peop le involuntarily. B e c a u s e t h e s e drugs can be covertly a d d e d to b e v e r a g e s in a social sett ing, s u b s t a n c e - i n d u c e d rape p o s e s un ique difficulties.

medicat ions , f lunitrazepam (Rohypnol), had been misused in this way. Rohypnol is a prescript ion med- ication available in 80 countries worldwide for the t rea tment of severe and debil i tat ing sleep disorders.

This tes t ing program, accessed by calling (800) 608-6540, uses an independent forensic toxicology laboratory certified by the U.S. Depar tment of Health and Human Services that follows strict chain-of-cus- tody procedures. The laboratory has highly sophisti- ca ted equipment capable of identifying a wide range of amphetamines , barbiturates, benzodiazepines (in- cluding flunitrazepam), cocaine, marijuana, codeine, heroin, and morphine through a three-s tage assay. Re- sults are returned in about a week to the hospital emergency department , rape crisis center, or law en- forcement agency that submit ted the sample.

Although media reports have focused on just a few substances , including Rohypnol, gamma hydroxybu- tyrate (GHB), a central nervous sys tem depressant that is manufactured illegally in the United States, and ketamine, a veterinary anesthetic, tes t results show that a much wider range of subs tances is be ing used. From June 1996 through May 1997, 266 tes ts were performed on urine samples of rape survivors who ap- peared to have symptoms of drug-related sexual as- sault. Ninety percent of the samples submit ted for analysis were obtained within 72 hours of ingest ion of the suspec ted substance, and the average t ime for

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The incidence of substances being misused to facilitate sexual assault is increasingly reported in some parts of the country. Numerous substances may cause symptoms of drowsiness, lack of muscle coordination and confusion, especially if combined with alcohol. A new urine test is available, free of charge to law enforcement agencies, rape crisis centers and hospital emergency rooms, that may help determine which substance was used and document the evidence for legal purposes.

The test is a series of three assays designed to detect certain drugs in the urine, including alcohol, amphetamines, barbiturates, benzodiazepines, cocaine, GHe, marijuana and opiates.

• The first assay, Abuscreen ONTRAK °, screens for benzodiazepines, it is a self-contained urinalysis test that provides easily inlerpreted results in less than three minutes without the use of instrumentation, and is designed to be used on site.

• The second assay, Abuscreen ONLINE ®, is a series of automated instrument-based diagnostic tests designed specifically to detect benzodiazepines in urine. It also can delect amphetamines, barbiturates, cocaine, marijuana and opiates.

• The third and final assay, gas chromatography/mass spectrometry (GC/MS), is a more specific chemical analysis that confirms the results of the ONTRAK and ONLINE tests. If a benzodiazepine is detected, the assay will determine which one it is. If flunitrazepam (Rohypnol), GHB (gamma hydroxybutyrate) or alcohol is present in the sample, the assay will confirm this.

This service is available free of charge to law enforcement, rape crisis centers and emergency rooms investigating cases of sexual assault.

The urine sample should be collected from the victim immediately to increase the likelihood that the drug wig be detected by the assays. In the case of Rohypnol, doses of a single 1 mg tablet have been detectable in the urine for 60 to 72 hours after ingestion. The amount of drug in the victim's urine at any particular time depends on the person's metabolism, the amount of drug consumed, and the length ol time that elapsed since the drug was ingested. You should refer to your local laws and procedures regarding collection of samples and chain of custody requirements.

Although the sample may be usable for up to seven days when stored at room temperature, it should be stored in a refrigerator or freezer to minimize degradation. The timing of the actual testing of the sample is less criticaI. If the sample is frozen, the test can be administered effectively even months later.

To access the testing capability, call 1-800-608-6540. You will be given an authorization number and a Federal Express account number. You also wgl be provided with instructions to ship the specimen to ElSohly Laboratories, ]nc (ELI), the independent, DHHS-certified forensic toxicology laboratory that conducts the analyses. This laboratory follows strict chain-of-custody procedures in handling samples.

Follow your normal chain-of-custody procedures in collecting and handling the urine sample. Place a security seal containing the authorization number across the cap of the bottle. Using the FedEx account number you were given when you called the 800-number, send Ihe urine sample in a liquid-tight container in a leak-proof bag in a protective cardboard box with a copy of the authorization and chain-of-custody forms via FedEx Priori[y Overnight delivery to ElSohiy Laboratories. Once the sample is received, test results will be reported in about ten days to the person completing the authorization form.

FOR TESTING, CALL:

1-800-608-6540 For general information about drugs and assault, call: 1-800-720-1076

EISohly Laboratories, Inc. 5 Industrial Park Drive, Oxford, MS 38655 Tel: 601-236-2609 Fax: 601-234-0253

Testing is provided as a service from Heffmann-La Roche Inc. Nutley, New Jersey 07110-1199

Figure 1 Poster shows details of drug testing for sexual assault victims.

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*None Found 155

Other Drugs 5 Barbiturates 1 Amphetamines 17

deine 2

Cannabinoids 39

Morphine/Opiates 2

Cocaine 23

Flunitrazepam Other 3 Benzodiazepines 46

Figure 2 Drug test results of urine samples from 266 reported rape cases in which drug use was suspected. The chart shows amphetamines, barbiturates, benzodiazepines, cannabi- noids, cocaine, and opiates. It does not show alcohol, gamma hydroxybutyrate (GHB), or other substances; tests for these began in March 1997. More than one substance was present in some samples.

A free drug t e s t i n g service has b e e n m a d e avai lable to h o s p i t a l e m e r g e n c y d e p a r t m e n t s , rape crisis centers , a n d l a w e n f o r c e m e n t a g e n c i e s by H o f f m a n n - L a Roche.

i nges t i on to ur ine s a m p l e w a s at 27 hours. Only th ree c o n t a i n e d R o h y p n o l - - o n e of t h e s e w a s a s p e c i m e n co l lec ted 10 to 13 hours after i nges t ion in Texas; the s e c o n d 18 hours after i nges t ion in Minneso ta ; and the th i rd 13 hours ' la ter in Arkansas . One h u n d r e d t e n s a m p l e s c o n t a i n e d e v i d e n c e of oJ;her control led s u b s t a n c e s - - m a r i j u a n a , cocaine , a m p h e t a m i n e s , co- de ine , morph ine , and o ther benzod iazep ines . Tes t ing for GHB a n d alcohol b e g a n in March 1997 and resul t s a re no t i n c l u d e d he re (Figure 2).

Signs and symptoms of drug ingestion A l t h o u g h t h e effects of s e d a t i n g s u b s t a n c e s m a y vary a c c o r d i n g to t he a m o u n t i n g e s t e d and the a m o u n t of a lcohol or o ther d rugs c o n s u m e d wi th the s e d a t i n g s u b s t a n c e , t he m o s t f requent ly o b s e r v e d s y m p t o m s inc lude the following: • A p p e a r a n c e of in tox ica t ion d i sp ropor t iona te to the

a m o u n t of a lcohol consumed , or de sp i t e lack of a lcohol c o n s u m p t i o n

• U n e x p l a i n e d d r o w s i n e s s a n d i m p a i r e d motor coord ina t ion

• Dizziness , confusion, impa i r ed j udgmen t , and loss of inh ib i t ion

• I m p a i r e d abi l i ty to r e m e m b e r detai ls . B e c a u s e Rohypnol, like some other d rugs of i ts

class, is p r e sc r i be d to t rea t severe s l eep d isorders , its e x p e c t e d ac t ions inc lude anxiolyt ic , an t iconvulsan t , and s e d a t i v e effects, as well as s lowing of p s y c h o m o - tor pe r fo rmance and musc l e relaxat ion. Numerous o ther s u b s t a n c e s m a y cause s imilar s y m p t o m s . W h e n u s e d properlyl Rehypnol p r o d u c e s s e d a t i v e effects w i th in 20 to 30 minutes , r e a c he s p e a k effect in 2 hours, and s u b s i d e s in 6 to 8 hours.

Collecting urine samples for forensic evidence The following gu ide l ines will help t he a c c u r a c y of the tes t : • Collect the ur ine s amp le i m m e d i a t e l y to i nc rea se

t he l ikel ihood tha t the d rug will be d e t e c t e d by assays . Collect a t leas t 10 ml of urine, b u t ideal ly '30 ml. In the case of Rohypnol, doses of a s ingle 1 m g t ab le t have b e e n d e t e c t a b l e in the ur ine for 72 hours or more after inges t ion .

• Store the s a m p l e in a clean, sealable , l iqu id - t igh t con ta ine r and p l ace a secur i ty seal con t a in ing the au thor iza t ion n u m b e r across the lid. Put t he con- t a ine r in a leakproof b a g in a p ro t ec t i ve ca rdboa rd box tha t is s t rong enough to w i t h s t a n d s h i p m e n t by Federa l Express . A l though the s a m p l e m a y be usab le for up to 7 days w h e n s to red at room tem- pera ture , it should be s tored in a refr igerator or freezer to min imize degrada t ion . The t i m i n g of the

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Call the test ing service at (800) 608-6540. Directions will be provided for sending the sample by Federal Express, free of charge, to the toxicology laboratory.

actual testing of the sample is less critical. If the sample is frozen, the test can be administered effectively even months later.

• Call the testing service at (800) 608-6540. Directions will be provided for sending the sample by Federal Express, free of charge, to the toxicology laboratory. Once the sample is received, test results are sent to the submitting agency in about 10 days.

Controlling illegal use of medications Although many of the drugs that are reportedly mis- used in sexual assault are legitimate prescription drugs in this country, others are manufactured or

imported illegally. Rohypnol, for example, is a fre- quently prescribed drug in 80 countries worldwide, but is not marketed in the United States; it is smug- gled into the United States through illicit channels. Hoffmann-La Roche has taken aggressive steps to halt diversion of Rohypnol to the United States from other countries, control its misuse, and educate law enforcement professionals, rape crisis centers, hospi- tal emergency departments, and consumers. The company is working closely with law enforcement agencies, universities, and rape crisis centers to sup- port their efforts to stop substance abuse and misuse.

For more information about this issue, health pro- fessionals and consumers may call Hoffmann-La Roche at (800) 720-1076.

Contributions to this column should be sent to Linda E. Ledray , RN, PhD, FAAN, Sexual Assault Resource Service, 525 Portland Avenue South, Minneapolis, MN 55415; phone (612)347-5832; E-mail: linda.ledray@co.hennepin.mn.us.

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