Uses. This quick-acting and long-lasting drug is widely used around the world for legitimate medical purposes. Flunitrazepam is prescribed to treat insomnia and anxiety, to relax muscles, to stop convulsions, and to calm people. In the 1990s it was Western Europe's most commonly prescribed calming and sleep-inducing medicine. The drug is administered to treat alcohol withdrawal syndrome, and experimental use in treating depression has found flu-nitrazepam promising. Some unauthorized use of the drug is believed to be for self-medication of depression and low self-esteem. The drug has specialized usefulness in surgery as a medication given prior to administration of anesthesia, and its tendency to reduce pressure inside the eyeball can avert the rise caused by the anesthetic succinylcholine (important if patients are at risk for glaucoma). In hospice care where doses can be higher and more frequent than normal, flunitrazepam has reduced nausea and vomiting from cancer chemotherapy.
Actions are similar to those of diazepam, but flunitrazepam is 7 to 10 times stronger. Nonetheless, compared to other benzodiazepine class drugs an overdose of flunitrazepam does not seem more poisonous, nor does flunitrazepam appear more prone to cause medical crises.
Drawbacks. The drug may cause euphoria, raise self-esteem, and give a sense of power in users while at the same time decreasing fear. Such effects may promote violence in a person who is already prone to such conduct, particularly when the substance is combined with alcohol.
Users are sometimes unable to remember what happened while they were under flunitrazepam's influence. Immediate effects aside, researchers have documented that people still experience trouble when doing laboratory memory tests 10 hours after taking a medical dose of the drug, a dose that may be much lighter than some abusers take. Many other benzodiazepine class drugs cause memory trouble as well, although their effect is less publicized than flunitrazepam's.
Flunitrazepam can slow reaction times, reduce ability to pay attention to tasks, and leave people too woozy and discoordinated to drive a car safely. Difficulty in driving has been demonstrated in simulations and in an instrumented automobile actually driven for several miles the day after drivers took a nighttime dose. In experiments (including a test of potential drug effects on shift workers) people took various sleep aids at bedtime; flunitrazepam harmed persons' ability to move their limbs the next day. Such effects appear to be dose-related; an experiment using much smaller doses found little or no impact on performance the next day. Large doses can cause breathing trouble. Injection can kill skin around the needle site.
Abuse factors. Abuse of the drug has become a concern among public health authorities in several countries. Under provisions of international treaties the federal government lists flunitrazepam as a Schedule IV controlled substance but has forbidden sale of this pharmaceutical in the United States. State governments have begun reclassifying the substance as Schedule I, certifying it as having no medical value and allowing anyone possessing it to be prosecuted under state law.
In the 1990s law enforcement agencies declared flunitrazepam to be a date rape drug, allowing men to commit sexual assault against unresisting victims who have foggy or even no memory of the circumstances. In this regard the drug is little different from alcohol, though faster acting. In a survey of 53 women who willingly used flunitrazepam, 10% said they were afterward assaulted physically or sexually. When 66 other "flunitrazepam users" described the tablet, many descriptions were of some other drug even though the people believed they had taken flunitrazepam. Untoward events may be real, but the identity of an involved drug may be less certain than law enforcement officials say. The U.S. Drug Enforcement Administration (DEA) says detection of fluni-trazepam is nearly impossible in rape cases because urine samples must be analyzed within 72 hours of ingesting flunitrazepam, making the drug's prevalence as a tool in sexual assault impossible to demonstrate. Nonetheless, the DEA describes the problem's extent as serious. A student of the topic found that from 1994 to 1998 a nationwide total of "at least" 26 sexual assaults "potentially involved" the drug. One laboratory conducted a two-year study of 1,179 urine specimens from sexual assault victims in 49 states, specimens selected because of suspicion that some drug was involved—and thereby more likely to have positive results than if samples were chosen randomly from sex crime cases. The lab found 6 positive for flunitrazepam (0.5%), 97 (8%) positive for a benzodiazepine class substance (a category including many drugs other than flunitrazepam), 451 positive for alcohol, and 468 negative for any drug of abuse that was searched for. A two-year study of 2,003 urine samples from sexual assault victims believed to have ingested a drug found less than 2% containing flunitrazepam or GHB. The same study reported that as of 1999 utilization of those two drugs seemed to be waning. Flunitrazepam's legal manufacturer has offered to provide free and definitive analysis of samples submitted by medical and law enforcement personnel. Researchers at the University of Miami report that detection of flunitrazepam in urine samples is easy and that, in contrast to ambiguous results from sex crime investigations, flunitrazepam had been confirmed in "up to" 10% of drunk driving cases in 1995 and 1996 in Miami-Dade County, Florida, but plummeted after the drug became Schedule I under state law in 1997.
Despite hype about flunitrazepam, a review article published in 1997 noted absence of evidence that the substance's actions differ from those of other drugs in the benzodiazepine class. Flunitrazepam is simply a very strong ben-zodiazepine, and its potency may have much to do with stories told about it. To produce similar drug effects, a small amount of flunitrazepam may be about equal to a large amount of some other benzodiazepine.
Tolerance can occur. A person's body can develop dependence with fluni-trazepam, resulting in a withdrawal syndrome if dosage stops. Withdrawal symptoms are similar to those with other benzodiazepine class substances. Severe cases can include delirium, hallucinations, and seizures. When researchers cut off the drug supply to dependent monkeys they became agitated and peevish, had tremors and poor control of muscles, and sometimes vomited and ran a fever. Although flunitrazepam is much stronger than diazepam, a canine experiment found those two drugs roughly equivalent in ability to produce dependence. Flunitrazepam reduced the morphine withdrawal syndrome in mice; if the same effect carries over to humans flunitrazepam might appeal to opiate addicts who have an unreliable supply of opiates. Surveys show flunitrazepam to be a favorite among opiate abusers, although among other people the substance seems no more attractive than other benzodiaze-pines.
Drug interactions. Alcohol and flunitrazepam boost each other's actions. Some illicit drug users find flunitrazepam to be a pleasing addition to a dose of inferior heroin, and some find that flunitrazepam eases harsh effects from cocaine. However, using multiple illicit drugs, particularly if the combination tends to make the body produce opposite actions simultaneously, is an invitation to problems. Buprenorphine disrupts the body's ability to break down flunitrazepam.
Cancer. Laboratory testing of the drug itself and of urine from rats and humans who have received doses indicates that flunitrazepam can induce gene mutations, a possible sign of cancer-causing potential.
Pregnancy. In pregnant women the drug passes into amniotic fluid and the fetal blood supply, although fetal levels are lower than maternal levels. Excessive muscular motions have been observed in a fetus after the drug is administered to a pregnant woman. When given to infants the drug lowers their blood pressure (an effect noted in adults as well). Although the drug passes into breast milk, levels are considered too low to affect a nursing infant if a mother does not take the drug regularly.
Additional scientific information may be found in:
Anglin, D., K.L. Spears, and H.R. Hutson. "Flunitrazepam and Its Involvement in Date or Acquaintance Rape." Academic Emergency Medicine 4 (1997): 323-26.
Calhoun, S.R., et al. "Abuse of Flunitrazepam (Rohypnol) and Other Benzodiazepines in Austin and South Texas." Journal of Psychoactive Drugs 28 (1996): 183-89.
Daderman, A.M., and L. Lidberg. "Flunitrazepam (Rohypnol) Abuse in Combination with Alcohol Causes Premeditated, Grievous Violence in Male Juvenile Offenders." Journal of the American Academy of Psychiatry and the Law 27 (1999): 83-99.
"Flunitrazepam Misuse and Abuse in South Africa." South African Medical Journal 89 (1999): 1155.
Mattila, M.A., and H.M. Larni. "Flunitrazepam: A Review of Its Pharmacological Properties and Therapeutic Use." Drugs 20 (1980): 353-74.
Ott, H., et al. "Anterograde and Retrograde Amnesia after Lormetazepam and Flunitrazepam." Psychopharmacology Series 6 (1988): 180-93.
Waltzman, M.L. "Flunitrazepam: A Review of 'Roofies.' " Pediatric Emergency Care 15 (1999): 59-60.
Woods, J.H., and G. Winger. "Abuse Liability of Flunitrazepam." Journal of Clinical Psychopharmacology 17 (1997, Suppl. 2): S1-S57.
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