Flunitrazepam (Rohypnol) Abuse in Combination with Alcohol Causes Premeditated, Grievous Violence in Male Juvenile Offenders

Anna Maria Daderman, MSc, and Lars Lidberg, MD, PhD

This study focuses on 19 juvenile offenders who were frequently intoxicated by flunitrazepam (FZ), almost exclusively under the brand name Rohypnol. Street names for Rohypnol tablets are Rophies, Ropies, Roofies, Ropes, Roches, Rochas, Rochas Dos, Rophs, Ropers, Ribs, R-25, Roach9s, Trip and Fall, Remem- ber All, Mind Erasers, Forget Pills, and the Date Rape Drug. An overdose of FZ gives an increased feeling of power and self-esteem, reduces fear and insecurity, and provides the belief that everything is possible. FZ is also associated with loss of episodic memory and with impulsive violence, particularly when combined with alcohol. The subjects were taken from a subpopulation of 47 male juvenile offend- ers from Swedish national correctional institutions. Background information for subjects was obtained by in-depth interviewing and personality inventories in- cluding the Zuckerman Sensation-Seeking Scales, the Eysenck Personality Ques- tionnaire, and the Karolinska Scales of Personality. Data concerning previous criminal offenses was obtained from the Swedish National Police Board. Almost all of the FZ abusers had been previously sentenced for serious .violent offenses. Our data suggest that FZ abused by psychiatrically vulnerable subjects (i.e., with high scores on boredom susceptibility and verbal aggression) poses a serious hazard both to the abusers as well as the community. Our results support the finding that FZ should be classified as a Schedule I drug (i.e., a drug similar to heavy narcotics).

.- .- This research was supported in part by grants from the Stockholm and senior physician at the Department of Swedish Alcohol Research Fund (to A.M.D.) and the Forensic Psychiatry. Universily Hospital, Huddinge, Swedish National Board of Forensic Medicine and by a Sweden. Some of the results Srom this study were pre- scholarship from the Swedish Medical Association, Di- sented by A.M.D. to the Annual Meeting of the Swedish vision of Alcohol and Drug Research (to A.M.D.). PhD Association of Alcohol and Drug Research, November student A. M. Diderman is affiliated with the Depart- 2-3, 1998, Norrkoping, Sweden and to the Annual Meet- ment of Clinical Neuroscience, Occupational Therapy, ing of the Swedish Medical Association, November 24- and Elder Care Research, Division of Forensic Psych- 26, 1998, GGtehorg, Sweden. Address correspondence to atry, Karolinska Institute, and the Department of Psy- Anna M. Didernian, Department of Clinical Neuro- chology, Division of Biological Psychology, Stockholm science, Occupational Therapy, and Elder Care Re- University, Stockholm, Sweden. Dr. Lidberg is Profes- search, Division of Forensic Psychiatry, Karolinska In- sor in Forensic Psychiatl-y at the Karolinska Institute in stitute, P.O. Box 4044, S-141 04 Huddinge, Sweden.

J Am Acad Psychiatry Law, Vol. 27, No. 1, 1999 DBderman and Lidberg

A number of studies indicate that aggres- Flunitrazepam (FZ) This drug, a BZ sive behavior in young males predicts with strong sedative properties, and diaz- substance abuse.lp4 The relationship be- epam are different from some other BZs tween aggression and alcohol intake is such as oxazepam, because of their rapid moderated by a complex group of vari- absorption and rapid entry into the brain. ables, including personality, experience, FZ is reported to be 10 times more potent expectations, provocation, and amount of than diazepam, causing muscle relaxation alcoh01.~ ~iczek~postulated that there and impaired judgment. In some cases it are pharmacological and behavioral de- can lead to amnesia (particularly antero- terminants in that subgroup of individuals grade amnesia) for up to eight hours and in whom various types of alcohol intoxi- can also induce excitability or aggressive cation increases aggressive and violent behavior in some users.16 The effect of behavior. In alcoholic violent offenders, the short-time amnesia causes those who only the impulsive subgroup has a low are intoxicated by FZ to be easily influ- concentration of 5-hydroxyindoleacetic enced by suggestions. The amnesia also acid (5-HIAA) in cerebrospinal fluid affects episodic memory, the ability to (CSF).' This finding may reflect de- recall personal experience. The drug also creased central serotonergic turnover, slows psychomotor performance. Seda- which in turn is associated with anxiety- tion occurs 20 to 30 minutes after admin- related intolerance to delay and deficient istration of a two-milligram tablet and impulse contr~l,~as well as with distur- lasts for approximately eight hours. bances of glucose metaboli~m.~ FZ was originally developed by Hoff- Overview man LaRoche in the 1960s and early 1970s as a rapidly acting hypnotic. It was Paradoxical Reactions Unexpected first launched under the trade name of and unpredictable reactions to benzodiaz- epines (BZs), particularly diazepam, have Rohypnol in Switzerland in 1975. FZ has been reported in earlier research. Para- been legitimately used in 64 different doxical reactions include depression,'" countries, often prior to surgery and to suicidal thoughts,' ' gross behavioral dis- treat insomnia. It is the most widely pre- turbances ranging from agitation to psy- scribed sedativelhypnotic in Europe. In chosis, and paranoid reactions, con- 1983, FZ was placed into Schedule IV at fusional stages. hypomanic and manic ac- the 1971 United Nations Convention on tivity, extreme garrulousness and states Psychotropic Substances. In March 1995, resembling alcoholic into~ication,'~ FZ was moved to Schedule 111 by the impaired recall (particularly delayed re- World Health Organization and was the ca11),I3 and hostility.14 DiMascio and col- first BZ to require more rigid control. The league~'~hypothesized that such para- Drug Induced Rape Prevention and Pun- doxical reactions may be "expected in ishment Act of 1996 (P. L. 104-305), re- patients with a history of poor impulse cently signed by President Clinton. makes control and aggressiveness. it a crime in the United States to give a

84 J Am Acad Psychiatry Law, Vol. 27, No. 1, 1999 Flunitrazepam Abuse in Male Juvenile Offenders controlled substance to anyone without The pattern of such mixed abuse and their knowledge with the intent of com- possible interactions in addicts has been mitting a violent crime. The U.S. federal reviewed by van der Lamz2 He noted government has recently classified Ro- paradoxical reactions to Rohypnol. in- hypnol as a Schedule I drug, which places cluding induced hostility and memory it in the same category as cocaine, heroin, disturbances ("black-outs7') and proposed and lysergic acid diethylamide (LSD; i.e., that "people with a hot-tempered charac- drugs with no medical purpose). FZ is not ter are especially at risk." currently legal in Canada, even with a In Sweden, FZ is legally available on prescription.'6 In Germany, a two-milli- the market. Rohypnol has been reported gram dose of FZ has recently been re- widely used among school children as moved from retail distribution and has young as 12 years old, as well as in high been restricted to hospital use only. This school students, commonly to enhance has been necessary because of the in- the effects of alcohol. Recently. Druid creasing abuse of FZ. and ~olingren~~examined a total of Noizmedical Use of Flunitrazepam 15.800 blood samples collected at medi- FZ is often used for purposes that are not colegal autopsies performed in Sweden. consistent with legal or medical guide- The results show that in 44 cases the lines. It is also reported to be popular pathologist had stated "intoxication in- among drug addicts. Teo and colleagues17 cluding solely FZ" (i.e., in which influ- reported Rohypnol abuse in Singapore as ence of alcohol or other substances and early as 1979 and emphasized its poten- other contributory factors could be ruled tial danger (i.e., violent and suicidal be- out) as the immediate cause of death. The havior, confusion with disorientation, and combination of alcohol and FZ abuse inability to recall relevant events). FZ is were also often the cause of death. In 139 the BZ most frequently abused in Malay- cases. the pathologist had stated "intoxi- sia and ~ustralia."~l9 cation in which more substance than FZ Abuse of FZ has been reported in and/or significant alcohol concentrations Western Europe and the Caribbean over were found" as the immediate cause of the last 10 years. Drug addicts often use death. FZ for various reasons (e.g., as a remedy Violent Behavior in Response to for the depression that follows a stimulant Flunitrazepain Research on violence high. to allay withdrawal symptoms and related to FZ abuse is sparse. Gaillard and gain a state of oblivion, and to enhance ~heli~~eau~~have, however, investigated the effects of low quality heroin) in addi- the effect of FZ on dream content. Com- tion to using opiates and cocaine.20 In a pared with subjects given placebo, FZ study conducted with nearly 1000 Span- subjects reported more verbal and physi- ish heroin addicts. it was discovered that cal aggressiveness in dream content. two of three subjects were BZ abusers In the United States, Rohypnol has and that the most preferred benzodiaz- been reported to aid in the commission of epine was FZ.~' rape and in many cases has been used as

J Am Acad Psychiatry Law, Vol. 27, No. 1, 1999 85 Ddderman and Lidberg a "date-rape" drug because of its ability to described several cases involving persons affect ~ill~ower.~~-~~The result is that who had repeatedly committed murder the victim knows something is happening and who had been admitted to forensic but is unable to do anything about it. psychiatric investigation in 1993.~'All of Because of the amnesia-inducing proper- the offenders, at the time of the murders. ties of FZ, the victim often can not re- had been intoxicated by both FZ and al- member what happened. cohol. The cases were subjected to foren- There is only one report of aggressive- sic psychiatric reexamination. but the ness as a side-effect of FZ in the Swedish court was unable to agree on whether the Medical Products Agency record; this offenders could be held responsible for was a case of a change in personality that their actions. The abuse of FZ in Sweden involved an attempted murder. This low has been involved in a number of impor- incidence of reported violence is consid- tant legal decisions in which it has been ered remarkable by the authors of the necessary to inform the courts, using ex- current report because of the fact that pert opinions, as to whether an offender their first-hand observations among juve- was suffering from a severe mental dis- nile delinquents and among violent of- order at the time of the crime and whether fenders indicates that hostile aggressive the conditions required for forensic psy- behavior is indeed a well-known side- chiatry treatment have been fulfilled. effect of this compound." It is also note- Purpose of the Present Study The worthy, that there are only 18 case study primary aim of the present study was to reports by the World Health Organization find answers to the questions related to (WHO) about such effects, most of them why some of male juvenile delinquents concerning aggressive reactions when pa- from Swedish national correctional insti- tients were treated with FZ for sleep dis- tutions abuse FZ and what drives these orders. subjects to abuse FZ when other juvenile The authors have noted in forensic psy- offenders resist such a temptation. chiatric patients that many of the violent Another aim was to compare prevalent situations occurred while the offenders background variables for the two sub- were acutely intoxicated by FZ. In several groups of interest (i.e., FZ abusers and cases, a series of violent crimes had been non-FZ abusers) such as, for example, committed. It is also noteworthy that the family situation. housing area, previous offenders in many of these cases had been treatment, childhood psychological con- intoxicated by both FZ and alcohol. tact, patterns of abuse, and previous crim- Kiithe Elmgren, MD, who is a fellow of inal offenses. It is also intended to com- The Legal Aid Council at The National pare the personality profiles of the FZ Board of Health and Welfare in Sweden, abusers with those of a group of non-FZ user juvenile offenders, with the purpose of discovering possible vulnerability fac- * A.M.D. has worked as a probation officer, and L.L. is a forensic psychiatrist and prison doctor. tors associated with FZ abuse.

86 J Am Acad Psychiatry Law, Vol. 27, No. 1, 1999 Flunitrazepam Abuse in Male Juvenile Offenders

Materials and Methods face-to-face interview lasted approxi- Study Subjects This study was per- mately 1.5 hours and covered background formed as part of a larger personality information, with a focus on sociological study conducted on 47 male subjects re- issues. cruited from four representative Swedish In-Depth Interview In the present national correctional institutions for juve- study, qualitative data choice and induc- nile offenders sentenced for serious of- tive analysis were used to conduct an fense~.~~."Subjects ranged in age from in-depth study of the subjects' abuse of 14 to 20 years and averaged 17 years FZ. The advantage of a qualitative ap- (SD = 1.2) and fulfilled the DSM-1v3' proach is that it produces a wealth of criteria for Conduct Disorder, implying detailed data about a small number of criminal activity, among other things, be- people and cases. Qualitative data pro- fore the age of 15 years. Subjects were vides depth and detail in the form of informed about the purpose of the study, direct quotations and careful descriptions and the study was approved by the Upp- of situations, events, people, interactions, sala University Ethics Committee. All of and observed behavior^.'^-^^ ~01dsteir-1~~ the residents of the participating institu- used such methods to highlight the causes tions were invited to participate. and only of juvenile delinquency and its prevention two declined. and remediation. Some of the subjects were treated by In the present study, semistructured in- doctors at the institutions (the most com- depth interviews, based on the interper- monly prescribed drug was oxazepam). sonal communication theory," were used The aim of this treatment was to reduce to gather background information that fo- the violent behavior of subjects, to reduce cused on psychological issues, experi- their dependency on other drugs (e.g., ences of emotional states in criminal sit- heroin, referred to by the subjects as uations, and aggressive behaviors while "chasing the dragon"), and to treat absti- acutely intoxicated by FZ. These inter- nence from alcohol or BZs. Almost 70 views took between one-half to two hours percent of the subjects were reported to depending on factors such as how artic- have been convicted of serious violent ulate the subject was, the subject's age, offenses two or more times. Three of four and previous experience of intoxication subjects reported early onset alcohol with FZ. abuse combined with other drugs or com- Generally speaking, the in-depth inter- binations of drugs. Subjects who had views for each subject may be described started drinking heavily before the age of as commencing in a topic-relevant but 25, and who had repeatedly lost their essentially nondirective, open-ended. and impulse control during their alcohol in- broadly structured manner. As the inter- take, were classified by some researchers view progressed, depending on richness as Type 2 alcoh01ics.~~ or paucity of information obtained, the Structured Interview The structured style became more specific, closed. and

J Am Acad Psychiatry Law, Vol. 27, No. 1, 1999 87 DBderman and Lidberg narrowly structured.+ Information evolv- fenses committed before the interviews ing from the interviews was transcribed are considered in the present study. and specifically labeled systematically in Personality Inventories The follow- the form of quotations. The main findings ing three personality inventories were ad- were typically comments relating to FZ. ministered to measure traits assumed to The abuse of BZs was established by a reflect the biological basis of personality. criterion applied to the self-reported in- The Karolirzska Scales of Personality formation. Subjects were specifically (KSP)~~This group of scales includes a asked: "Are you a benzodiazepine abus- socialization scale based on items from er?" If a subject answered "Yes" to this the Gough Delinquency Scale.39The KSP question, he was then asked: "Are you a consists of 135 questions grouped into 15 flunitrazepam abuser?" An overconsump- scales: impulsiveness, monotony avoid- tion of FZ was defined as anything ance, detachment, socialization, social greater than a two-milligram dose. The desirability, somatic anxiety, muscular BZ abusers were asked to give their rea- tension, psychic anxiety. psychasthenia, sons for a greater preference for FZ. inhibition of aggression, and the aggres- Acute intoxication by FZ was also inves- sivness-related scales: indirect aggres- tigated to gather information concerning sion, verbal aggression. irritability, suspi- how the violence manifested itself. The cion, and guilt. Of particular importance intention of the interviews was to gain an with regard to the present study are: (1) insight into the FZ abusers' thoughts and the monotony avoidance scale (measuring feelings, the nature of the experiences sensation-seeking using more general occurring during abuse, and the behavior items correlated with the General Sensa- patterns occurring before, during, and tion Seeking scale (G) at r = SOand the about two weeks after intoxication. Boredom Susceptibility (BS) at r = .5 1,40 The Swedish National Police Board the correlations for the subjects in this Additional information about offenses study were earlier found to be r = .46 for committed by subjects after they had G and r = .29 for BS~',30); and (2) ag- reached the age of 15 was supplied by the gressiveness-related scales adapted from Swedish National Police Board. This data the Buss-Durkee Hostility ~nventory,~' covered all offenses leading to public which concern indirect aggression (re- prosecution and conviction, and was ob- flecting undirected anger), verbal aggres- tained for all subjects 18 months after the sion (including arguing, shouting, and be- interviews. It was hoped that this infor- ing overly critical), irritability, suspicion mation would supplement the interview (including projection of ill will onto oth- data regarding previous criminal of- ers), and guilt (reflecting aggressiveness fenses. Only information concerning of- with or without guilt feelings). The Eysenck Personality Question-

+ All of the interviews were carried out by A.M.D., who naire (EPQ-I)~~This questionnaire in- has been trained in in-depth interview techniques at the cludes an impulsivity scale from the Im- Department of Psychology, Stockholm University, Stockholm. Sweden. pulsiveness-Venturesomeness-Empathy

88 J Am Acad Psychiatry Law, Vol. 27, No. 1, 1999 Flunitrazepam Abuse in Male Juvenile Offenders inventory.43 The EPQ-I consists of 114 sence of theory. When good ideas were truelfalse questions and is classified into generated in thoughts, they were imme- an extraversion scale, a neuroticism scale, diately transcribed in the form of a memo. a psychoticism scale, and a lie scale. By comparing the data as they were col- The Zuckerman Sensation-Seeking lected, they could be formulated into core Scales-Form V (SSS-v)~~ The SSS-V categories, and modifications could then consists of 40 forced-choice items (10 be made to help explain surprising or new items for each scale) classified into the variations. This procedure aided in the following factors: Thrill and Adventure creation of theoretical connections at a Seeking (TAS), Experience Seeking (ES), more abstract level and transcended pre- Disinhibition (Dis), Boredom Suscepti- ceding theories by placing all relevancies bility (BS). Of particular importance to in a multivariate schema possessing both the present study are the ES scale reflect- greater scope and a higher conceptual ing the pursuit of new sensory experi- level. ences in music, art, drugs, and spontane- The aims of the present study were also ous lifestyle, and the BS scale describing to investigate the subjects' backgrounds aversion to routine activities, work, and and the nature and frequency of criminal people regarded as boring. The sensation- offenses committed by them while under seeking scales are presumed to reflect the influence FZ. Typescripts of 47 struc- levels of catecholamines and their respec- tured interviews and information from the tive enzymes and are based on the con- National Police Board constituted the raw cept of an optimal level of arousal, as- data of the study with regard to the main suming that individual differences in demographic characteristics (e.g., family optimal levels of stimulation are basic situation, drug abuse, criminal offenses personality dimension^.^' committed by the subjects). Nonparamet- Treatment of Data The qualitative ric statistical analyses (Kendall's W) were data are presented in combination with applied to investigate groups differences. the quantitative data. The data from the The use of the personality scale scores in-depth open-ended interviews consist of was also intended to enable a comparison direct quotations from FZ abusers about between juvenile offenders who were fre- their experiences, opinions, feelings, and quent FZ abusers and juvenile offenders knowledge in relation to the frequent who were not FZ abusers. An examina- overconsumption of FZ. The first step in tion of the group differences was carried gaining theoretical sensitivity was to out by applying one-way analyses of vari- analyze the interview notes with as ance (ANOVAs). Post hoc tests (Scheffe) few predetermined ideas as possible. were also carried out to highlight the dif- Grounded he or^^^ assumes that part of ferences between groups. To adjust for the method is the writing of theory (data the effect of age, the mean personality must be coded, ideas noted, and the re- scores for subjects were transformed into sulting memoranda sorted in a particular age-related and sex-related T scores for way). Conceptual ideas become the es- the Zuckerman SSS. These calculations

J Am Acad Psychiatry Law, Vol. 27, No. 1, 1999 89 DAderman and Lidberg were based on the means and standard perceptual and cognitive processes (i.e., deviations from a group of introductory 'a black-out'), lasting sometimes up to male psychology students (n = 686) at two weeks and highly practical in con- the University of l el aware.^^ For the junction with police inquiries. In contrast KSP and EPQ-I scales. a similar transfor- to FZ, other BZs were reported to be mation was performed based on a ran- "dangerous" in combination with alcohol; domly selected group of healthy male for example, subjects could experience subjects (n = 196; range 20 to 65 years) breathless and palpitations. FZ was also from within the greater Stockholm area.45 reported to have a lot of "practical" prop- erties; it was possible to take five to six Results milligrams of this drug still be capable of All of the BZ abusers (n = 19) were driving. The majority of abusers also re- abusing FZ and were frequent intoxicated ported that FZ reduced their level of anx- by it. The most preferred FZ compound iety, whereas other BZs did not exhibit was Rohypnol (at the time of this writing, the same anxiolytic effect. The drug was there are four compounds legalized for also used to reduce anxiety, often in re- medical use in Sweden that include FZ). lation to previous adjustmentlpunish- Grounded Theory: Why Just Fluni- ment, and to avoid having to face up to The main reason given by trazepam? social norms. Under the influence of the our study subjects for frequently being in drug it was possible, for example, to rush an advanced state of intoxication with FZ into an unknown apartment and totally was to obtain an increased feeling of destroy it, wreck cars, or break a shop power and self-esteem and to feel that window. The ability to commit such vio- everything was possible (typified by the lent acts was reported desirable when tak- comments: "This drug does just what I ing the role of "torpedo" (a person who want to change. It is so much stronger, I kills or assaults others for money). am able to do everything"; and "My brain In conclusion, it can be construed that is asleep, and my body does as it wants"). All of the FZ abusers had experienced all FZ abusers considered the dysfunction changes in reality, which could vary from of fundamental innate emotional reac- person to person and from one occasion tions, such as anger, fear, disgust, and to another. sadness as a desirable effect. The follow- The FZ abusers have no conscience or ing quotations exemplify this attitude: "I guilt about serious violent offenses didn't feel any emotion, when I stabbed ("When I stabbed him it felt like putting a him five times stabs"; "My friend had knife into butter"). Another reported ef- taken an overdose and died, and I didn't fect was that of being able to achieve a even notice." Such dysfunction, which generally calm, "antianxious," and me- has been experienced by all FZ abusers, is thodical state, which was desirable before described as both frightening and highly committing crimes. Similarly, FZ could exciting and is accompanied by a height- be used to achieve a severe disturbance in ened sense of power and self-esteem.

90 J Am Acad Psychiatry Law, Vol. 27, No. 1, 1999 Flunitrazepam Abuse in Male Juvenile Offenders

The Extent of Flunitrazepam Abuse reported using violence in their daily life The subjects did not describe themselves as a means of communication (typified by as "hooked" on FZ. They used FZ for its the comment: "I say nothing. I just hit"). many "good" effects, which included the Almost all FZ abusers also reported hav- practical side in relation to criminal acts. ing been convicted of serious violent of- They defined two to six milligrams as a fenses including homicide. attempted desirable dose of FZ. Alcohol strengthens murder, assault of a serious nature, arson, the effect of FZ. Most of the FZ abusers and armed robbery. In some cases such used FZ only occasionally or when "nec- crimes had been committed several times, essary." Only one of the subjects reported and there were also occasions where the heavy, long term FZ abuse and depen- crimes had been committed but the sub- dence (20-30 mg of FZ every day during jects had not been caught. Almost all of the previous two- to three-year period). the FZ abusers had been caught more then Ways to Obtain FZ The FZ abusers three times for their crimes before the age were in the habit of having a lot of FZ on of 15, and approximately 75 percent re- hand (1,000 milligrams was not rare). FZ ported selling drugs as a main source of was obtained in a number of specific income. ways: the illegal drug market (the reported No significant differences were found price was low at 10 to 15 Swedish crowns between the two subgroups in demo- per milligram. corresponding to $1-2 U.S.): graphic data or on any of the other back- stealing from a pharmacy or from senior ground factors (Table 1). citizen apartments; stealing from other The number of criminal sentences for drug addicts; and obtaining it from a sup- FZ abusers and non-FZ abusers are plier at parties (reported as frequently shown in Table 2 in relation to the type of available). Only two subjects had been crime committed. There were no signifi- prescribed FZ by their doctors. cant differences between the two sub- Flunitrazepam Abusers and Their groups in this respect. Among the FZ Backgrounds The FZ abusers ranged in abusers, there were also subjects who age from 16 to 20 years and averaged were alcohol abusers (n = 14). Similarly, 17.3 years (SD = 1.1 years). The subjects there were 16 alcohol abusers among the who were non-FZ abusers (n = 28) were non-FZ abusers. It was notable, however, used as a comparison group for the pur- that there were no significant differences poses of this study and ranged in age from between the subgroups regarding the type 14 to 20 years (M = 17 2 1.3 SD). There and number of criminal offenses. Also, were no significant differences between there were no significant differences as to subgroups with regard to age. the type and number of criminal offenses The results showed that all of the FZ between those subjects who were FZ abusers except one had a history of vio- abusers (n = 19) and those who were lent behavior. In these cases, the subjects only alcohol abusers (n = 16).

J Am Acad Psychiatry Law, Vol. 27, No. 1, 1999 DBderman and Lidberg

Table 1 Comparison of Background Factors (data from structured interviews) for a Group of Juvenile Offenders from Four Swedish Correctional Institutions (n = 47) at age 17 (SD = 1 .2)a FZ Non-FZ (n = 19) (n = 28) Background Factors No. of Subjects No. of Subjects Sentenced to violent crimes two or more timesb 17 16 Family situation Biological parents both born in Sweden 6 16 One parent is immigrant Swedish-born mother Swedish-born father Parents both immigrants Mother Swedish-born, father unknown Sibling(s) criminal Sibling(s) unknown, father criminal Father addicted to alcohol or drugs Mother addicted to alcohol or drugs Father criminal Father unknown Father deceased Mother deceased Housing Area Metropolitan areaC Previously sentenced to be treated in a correctional institution One to two times Three times or more Childhood psychological/psychiatric contact 8 1

The subjects are divided into two subgroups: flunitrazeparn abuse (FZ, n = 19) and non-flunitrazeparn abuse (non-FZ, n = 28). All BZ abusers were also FZ abusers. Wiolent crimes against officials are not included. "Stockholm, Gothenburg, and Malrnoe and surrounding counties.

Personality Scale Scores in Flunitraz- on the sensation-seeking-related monot- epam Abusers and Non-Fhnitrazepam ony avoidance scale (F(1,45) = 2.84, p < abusers Mean personality scale scores .lo). The FZ abusers also displayed are presented in Figure 1 in the form of T higher scores on the BS subscale from the scores for the KSP sensation-seeking- SSS-V (F(1,45) = 5.36. p < .05), as well related monotony avoidance scale and ag- as tendencies toward higher scores on the gression scale. The FZ abusers differed ES subscale (F(1,45) = 3.57, p < .lo) significantly from the non-FZ abusers, and the G scale (F(1,45) = 3.18, p < .lo) displaying higher scores on the verbal in comparison with the non-FZ abusers aggression scale (F(1,45) = 8.00, p < (see Fig. 2). .01). In addition, the FZ abusers also There were no significant differences showed a tendency toward higher scores between the two subgroups on the other

92 J Am Acad Psychiatry Law, Vol. 27, No. 1, 1999 Flunitrazepam Abuse in Male Juvenile Offenders

Table 2 Number of Offensesa (data from official records) for a Group of Juvenile Offenders from Four Swedish Correctional Institutions (n = 47) at age 17 (SD = 1.2) FZ Non-FZ (n = 19) (n = 28) Type of Offenses (No. of Subjects) (No. of Subjects) Violent offensesb Robbery Severe violent offensesC Weapons offenses Theft offenses Inflicting damage and arson Narcotic offenses Traffic violations Other crimes aOnly crimes committed up to the date of interview are reported. The subjects are divided into two subgroups: flunitrazepam abuse (FZ, n = 19) and non-flunitrazepam abuse (non-FZ, n = 28), shown in relation to type of offense. bSevere violent offenses are not included. "Murder, manslaughter, and severe cases of assault.

KSP or SSS-V scales. Both groups, how- between the two subgroups. Interestingly, ever, showed extremely low levels of so- this was true also with regard to the psy- cialization as measured by the KSP, each choticism scale; in fact, the scores re- scoring about three SD below the stan- vealed slight tendencies in the expected dard population mean. No differences direction (i.e.. the FZ abusers displayed were found for any of the Eysenck scales

I FZ abusers Nan-FZ sburcrr V Nomame maler I I FZ abuses Nan-FZ abusers v Normative maler I 70 i

6' 45' TAS ' ES ' Dir ' BS* ' G SS-V w.ale\ M IA VA" Irr S ' G KSP walcs Figure 2. Comparison of mean personality scale Figure 1. Comparison of mean personality scale scores presented as T scores for a group of juvenile scores, presented as T scores for a group of juvenile offenders from four Swedish correctional institutions offenders from four Swedish correctional institutions (n = 47) at age 17 (SD = 1.2) The subjects are divided (n = 47) at age 17 years (SD = 1.2). The subjects are into two subgroups; flunitrazepam abuse (FZ, n = 19), divided into two subgroups: flunitrazepam abuse (FZ, and non-flunitrazepam abuse (non-FZ, n = 28). Re- n = 19), and non-flunitrazepam abuse (non-FZ, n = sults from one-way ANOVAs are reported (significance 28). Results from one-way ANOVAs are reported (sig- level *, p < .05), along with significant t (5% level) for nificance level **, p <.01), along with significant t (5% subgroup comparisons (Scheffe); TAS, Thrill and Ad- level) for subgroup comparisons (Scheffe); M, Monot- venture Seeking; ES, Experience Seeking; Dis, Disin- ony Avoidance; /A, Indirect Aggression; VA, Verbal hibition; BS, Boredom Susceptibility; G, General Sen- Aggression; IrR, irritability; S, Suspicion; G, Guilt. sation Seeking Scale.

J Am Acad Psychiatry Law, Vol. 27, No. 1, 1999 93 Ddderman and Lidberg

Table 3 Comparison of Type and Extent of Drug Abuse for Specific Drugs (data from structured interviews) for a Group of Juvenile Offenders from Four Swedish Correctional Institutions (n = 47) at age 17 (SD = 1.2)" FZ Non-FZ (n = 19) (n = 28) No. of No. of Type of Drug Frequency of Abuse Subjects Subjects Alcohol Often (and involved in almost all of their own crimes) Amphetamine and Occasionally (parties; maximum 1-2 times per month) cocaine (also crack) Often (1-2 times per week) Every day Anabolic steroids Often; sometimes every day Cannabis (hashish Occasionally (maximum 1-2 times per month) and marijuana) Often (1-2 times per week) Every day LSD and ecstacy Occasionally ("rave" parties; maximum 1-2 times per month) Often (1-2 times per week) Opiates (mainly Every day inhaling heroin, referred to as "chasing the dragon")

The subjects are divided into two subgroups: flunitrazepam abuse (FZ, n = 19) and non-flunitrazepam abuse (non-FZ, n = 28).

higher scores in comparison with the not FZ abusers and showed a preference non-FZ abusers). for other drugs. About 40 percent of those The Substance Abuse Pattern in who abused FZ and amphetamine and/or Fhnitrazepain Abusers All of the BZ cocaine were daily amphetamine addicts. abusers used FZ, and about 30 percent of About 80 percent of those who abused FZ the FZ abusers (six subjects) used only and were addicted to cannabis and/or Rohypnol; the remaining 13 subjects used marijuana (foremost hashish) were daily FZ compounds other than Rohypnol (un- cannabis addicts. And about half of those der the brand names Fluscanol, Flunitraz- who abused FZ and hallucinogenic drugs, epam, and Flupam) as well as other BZs such as LSD and ecstasy, used these such as Diazepam, Oxazepam, or Nitraz- drugs regularly, especially in connection epam. Most of the subjects in this sub- with "rave" parties. Some theoretical con- group combined FZ with other drugs and cepts, together with results regarding the alcohol as shown in Table 3. There were, FZ abusers' personality traits and the re- however, no significant differences be- sults from the application of Grounded tween the FZ abusers and those who were Theory are presented in Figure 3.

94 J Am Acad Psychiatry Law, Vol. 27, No. 1, 1999 Flunitrazepam Abuse in Male Juvenile Offenders

cians and judges) to help them understand how the drug functions and the ways in which FZ is obtained. In Sweden, about 80 percent of BZs are prescribed not by specialist but by pri- mary care physicians who are often un- aware of the adverse effects that occur when this drug is abused.46 One of the major findings of this study was that sub- jects reported using FZ in an attempt to reduce insecurity and anxiety. The FZ abusers also reported a loss of episodic memory, which has also been found in earlier research. George and D~ndee~~ Figure 3. Illustration of a theoretical psycho-phar- found that FZ dose-related amnesia lasted maco-biological model, which is supported by present study. Paradoxical rage reactions because of acute slightly longer than that associated with intoxication by flunitrazepam would result from a dis- inhibition phenomenon in the serotonergic mechanism diazepam. The amnestic effects produced and personality traits, assumed to reflect the biological by FZ may be desirable in the clinical basis of personality (psychiatric/psychological vulnera- bility). setting but not in offenders. When FZ is used as a presurgical medication, the am- nestic effects tend to diminish the un- Discussion pleasant memory related to surgical pro- This study is the first to use in-depth cedure. The present study showed that interviews to obtain a greater understand- memory loss allowed FZ abusers to forget ing of the effects of acute intoxication by experiences of earlier violent acts. conse- FZ, particularly when used in combina- quently influencing their behavior. The tion with alcohol, with regard to out- drug could be used effectively by violent comes in the form of criminal behavior offenders to avoid having a guilty con- and enhanced violence. science and to provide a useful loss of This study has focused on 19 extreme episodic memory when faced with inquir- FZ abusers also known to have severe ies. conduct ,disorders. All were young male The findings of this study suggest that juvenile offenders admitted to Swedish three of four FZ-abusing subjects suffered correctional institutions for violent of- from Type 2 alcoholism. A biochemical fenses. The comparison group was also basis of alcoholism and impulsivity in recruited from the same institutions. The Type 2 alcoholics may be attributable to a FZ abusers provided a great deal of in- low turn-over of CSF monoamine trans- depth information concerning the effects mitters. FZ has also been noted to reduce of FZ that may be highly useful for the serotonin turn-over. 48.49 Used together staff at correctional institutions, doctors, with alcohol or other drugs, FZ is re- and other decision-makers (e.g., politi- ported to have devastating consequences

J Am Acad Psychiatry Law, Vol. 27, No. 1, 1999 95 Diderman and Lidberg leading to behavior that is more consis- der in conjunction with substance abuse. tent with wild animals. FZ abuse can be The subjects in Tiihonen and cowork- directly linked to violent assaults and acts er~'~'study were diagnosed with organic of murder. This association may be espe- psychosis, had criminal records, and were cially strong in impulsive subjects. abusers of alcohol. No subgroup differences were found The FZ abusers in the current study between the FZ abusers and the non-FZ belonged to a group of severely conduct- abusers regarding the type and number of disturbed young male juvenile offenders. offenses committed, which may be due to They scored very high on core psychop- the fact that almost 75 percent of the BZ athy-related traits, such as impulsivity abusers had previously been retained and sensation seeking and somatic anxi- within correctional institutions more than ety, and scored low on conformity (i.e., three times. Obviously, the subjects were sociali~ation).~~~ 3' Based on these facts, unable to commit further offenses during it seems possible that FZ acts as a tran- their confinement. Only about 20 percent quilizer by increasing hostility in vulner- of the subjects from the comparison able subjects, leading to a calmer state group had been previously sentenced to and reducing the level of anxiety. It is be treated in correctional institutions interesting that subjects displayed higher three times. Furthermore. a close inspec- scores on sensation-seeking scales. espe- tion of the information given by the sub- cially the boredom susceptibility scale, jects regarding violence, in conjunction which reflects a dislike of routine activ- with the data obtained from official ity, of dulllboring people, and of an en- sources, indicated that many of the vio- vironment that does not change. Further- lent crimes remained undiscovered by of- more, the FZ abusers also scored high on ficial authorities; this explains why it was the verbal aggression scale, reflecting a not possible to adequately investigate the readiness to enter into arguments follow- effect of FZ on the severity of criminal ing minor provocations, a tendency to offenses in terms of the sentences in each berate people when annoyed, and the fre- subgroup. quent use of swear words. As stated previously, there are few case The violence of FZ abusers was both reports to date relating specifically to FZ severe and commonplace. All of the stud- abuse that describe patterns of behavior ied FZ abusers except one were recidi- and evidence of criminality. The experi- vists, and all had committed serious ence of power and overwhelming self- crimes of violence. All except one of the esteem in FZ abusers appears to be a subjects had been treated on psychiatric pharmacological effect but appears also wards or in correctional institutions sev- to depend on the predisposing personal- eral times, 75 percent of the subjects on ity. Tiihonen and coworkers50 found that three or more occasions. This frequency the probability for committing a violent implies that the subjects had been within offense was enhanced 80 times when the correctional system for many years. there was a coexisting personality disor- Most subjects had been subjected to

96 J Am Acad Psychiatry Law, Vol. 27, No. 1, 1999 Flunitrazepam Abuse in Male Juvenile Offenders environmental therapy, but only one of ish government should reclassify all FZ the institutions used in the study had the compounds as drugs similar to heavy nar- possibility to offer cognitive behavior cotics. Although the effect of long term therapy. FZ abuse has not been systematically A number of WHO case reports based studied, the results of the present study on both male and female subjects have provide some suggestions about the short indicated that FZ causes a state of hostil- term effects of FZ abuse in a violent ity in men. and memory loss in both men population. Once the positive effects of and women. Those case reports did not, FZ have been experienced by young male however, include information about offenders, they usually wish to reexperi- whether the subjects were also abusing ence these effects and often take FZ pur- alcohol in addition to FZ. The abuse of posefully before committing violent of- FZ together with alcohol use is reported fenses. to be commonplace among Swedish juve- niles. At the time of this writing, FZ is the Acknowledgments most popular compound among Swedish drug abuser^.^' This may have something We thank the staSS of the correctional institu- tions for their cooperation and patience and the to do with the fact that juveniles read the institutionalized young men who volunteered their pharmacy compendium.52 The pharmacy time. We are also grateful for the general encour- compendium. openly available at phar- agement and help of Jan-Erik HBljebo, head of the Sundbo SchoolIBorstal at the time of this investi- macies in Sweden, describes the adverse gation, and Bengt Dahleflod, psychologist at the effects of FZ and the fact that FZ same school. We thank Professor of Pharmacology strengthens the effect of alcohol. Re- Lars Oreland, Uppsala University (Uppsala, Swe- cently, there have been reports in Swed- den), for reviewing previous drafts of this manu- script and Assoc. Professor Henrik Belfrage and ish newspapers describing some very se- Susanna Strand, MSc, Forensic Psychiatric Cen- vere cases of murder, assault, robbery, ter, Research Unit, Vaxjii Sor help in the nonpara- and kidnapping that were "calmly" car- metric statistical analyses. ried out by both juvenile delinquents and adults while under the influence of the FZ References drug. McCord W, McCord J: Origins of Alcohol- Our study indicates that FZ is the drug ism. Stanford, CA: Stanford University Press, of choice among Swedish juvenile delin- 1960 Andersson T, Bergnian LR, Magnusson D: quents. and there are reports to suggest Patterns of adjustment problems and alcohol that it can cause violence. Presently, it is abuse in early adulthood: a prospective longi- tudinal study. Dev Psychopath01 1: 1 19-3 1, easy for youths and older abusers to ob- 1989 tain FZ on the illegal drug market. Ag- Robins LN, McEvoy L: Conduct problems as gressive behavior resulting from the use predictors of substance abuse, in Straight and Devious Pathways from Childhood to Adult- of FZ is becoming more widely recog- hood. Edited by Robins LN, Rutter M. New nized in Sweden. This fact alone would York: Cambridge University Press, 1990 van Kammen WB, Loeber R, Stouthammer- suggest that the prescription of FZ in Loeber M: Substance use and its relationship Sweden should be restricted. The Swed- to conduct problems and delinquency in

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