View source for Flunitrazepam

{{short description|Benzodiazepine sedative}}
{{Use mdy dates|date=October 2015}}
{{Infobox drug
| Watchedfields = changed
| class = [[Benzodiazepine]]
| verifiedrevid = 477167367
| drug_name = 
| type = 
| IUPAC_name = 5-(2-fluorophenyl)-1-methyl-7-nitro-1''H''-benzo[''e''][1,4]diazepin-2(3''H'')-one
| image = Flunitrazepam structure.svg
| image_class = skin-invert-image
| width = 200
| alt = 
| caption = 
| image2 = Flunitrazepam-from-xtal-3D-balls.png

<!--Clinical data-->| pronounce = {{IPAc-en|ˌ|f|l|uː|n|ᵻ|ˈ|t|r|æ|z|ᵻ|p|æ|m}}
| tradename = Rohypnol
| MedlinePlus = 
| licence_EU = 
| licence_US = 
| pregnancy_AU = C
| pregnancy_US = 
| pregnancy_category = 
| legal_AU = S8
| legal_BR = B1
| legal_BR_comment = <ref>{{Cite web |author=Anvisa |author-link=Brazilian Health Regulatory Agency |date=2023-03-31 |title=RDC Nº 784 - Listas de Substâncias Entorpecentes, Psicotrópicas, Precursoras e Outras sob Controle Especial |trans-title=Collegiate Board Resolution No. 784 - Lists of Narcotic, Psychotropic, Precursor, and Other Substances under Special Control|url=https://www.in.gov.br/en/web/dou/-/resolucao-rdc-n-784-de-31-de-marco-de-2023-474904992 |url-status=live |archive-url=https://web.archive.org/web/20230803143925/https://www.in.gov.br/en/web/dou/-/resolucao-rdc-n-784-de-31-de-marco-de-2023-474904992 |archive-date=2023-08-03 |access-date=2023-08-16 |publisher=[[Diário Oficial da União]] |language=pt-BR |publication-date=2023-04-04}}</ref>
| legal_CA = Schedule I
| legal_DE = Anlage III
| legal_UK = Class C
| legal_US = [[List of Schedule IV drugs|Schedule IV (Schedule I trafficking penalties, however)]]
| legal_UN = Psychotropic Schedule III
| legal_status = SE: Förteckning II
| addiction_liability = High<ref name="Ries-2009">{{cite book| vauthors = Ries RK |title= Principles of addiction medicine|date=2009|publisher=Wolters Kluwer/Lippincott Williams & Wilkins|location=Philadelphia|isbn=978-0-7817-7477-2|page=106|edition=4|url=https://books.google.com/books?id=j6GGBud8DXcC&pg=PA106|url-status=live|archive-url=https://web.archive.org/web/20170908135444/https://books.google.com/books?id=j6GGBud8DXcC&pg=PA106|archive-date=8 September 2017}}</ref>
| routes_of_administration = [[Route of administration#Oral|Oral]]

<!--Pharmacokinetic data-->| bioavailability = 64–77% (by mouth)<br />50% (suppository)
| metabolism = [[Liver]]
| metabolites = 7-aminoflunitrazepam, [[desmethylflunitrazepam]] and [[Nifoxipam|3-hydroxydesmethylflunitrazepam]]
| elimination_half-life = 18–26 hours
| excretion = [[Kidney]]

<!--Identifiers-->| IUPHAR_ligand = 4193
| CAS_number_Ref = {{cascite|correct|??}}
| CAS_number = 1622-62-4
| ATC_prefix = N05
| ATC_suffix = CD03
| PubChem = 3380
| DrugBank_Ref = {{drugbankcite|correct|drugbank}}
| DrugBank = DB01544
| ChEBI = 31622
| ChemSpiderID_Ref = {{chemspidercite|correct|chemspider}}
| ChemSpiderID = 3263
| UNII_Ref = {{fdacite|correct|FDA}}
| UNII = 620X0222FQ
| KEGG_Ref = {{keggcite|correct|kegg}}
| KEGG = D01230
| ChEMBL_Ref = {{ebicite|correct|EBI}}
| synonyms = roofies, floonies
| ChEMBL = 13280

<!--Chemical data-->| C = 16
| H = 12
| F = 1
| N = 3
| O = 3
| smiles = CN1C(=O)CN=C(c2ccccc2F)c2cc([N+](=O)[O-])ccc21
| StdInChI_Ref = {{stdinchicite|correct|chemspider}}
| StdInChI = 1S/C16H12FN3O3/c1-19-14-7-6-10(20(22)23)8-12(14)16(18-9-15(19)21)11-4-2-3-5-13(11)17/h2-8H,9H2,1H3
| StdInChIKey_Ref = {{stdinchicite|correct|chemspider}}
| StdInChIKey = PPTYJKAXVCCBDU-UHFFFAOYSA-N
| melting_point = 170-172
}}

<!-- Definition and medical uses -->
'''Flunitrazepam''', sold under the brand name '''Rohypnol''' among others,<ref name=generics/> is a [[benzodiazepine]] used to treat severe [[insomnia]] and assist with [[anesthesia]].<ref name="NSW-PSB">{{cite web|url=http://www.health.nsw.gov.au/pharmaceutical/Documents/guide-flunitraz-alpraz.pdf |archive-url=https://web.archive.org/web/20140623033759/http://www.health.nsw.gov.au/pharmaceutical/Documents/guide-flunitraz-alpraz.pdf |archive-date=2014-06-23 |url-status=live|title=Prescribing of Benzodiazepines Alprazolam and Flunitrazepam|work=Pharmaceutical Services Branch|publisher=New South Wales Health|date=November 2013}}</ref> As with other [[hypnotic]]s, flunitrazepam has been advised to be prescribed only for short-term use or by those with chronic insomnia on an occasional basis.<ref name="NSW-PSB"/>

<!-- Society and culture -->
Flunitrazepam was patented in 1962 and came into medical use in 1974.<ref name=Fis2006>{{cite book | vauthors = Fischer J, Ganellin CR |title=Analogue-based Drug Discovery |date=2006 |publisher=John Wiley & Sons |isbn=978-3-527-60749-5 |page=53X |url=https://books.google.com/books?id=FjKfqkaKkAAC&pg=PA53X }}</ref> Nicknamed "roofies" or "floonies", it is widely known for its use as a [[date rape drug]].<ref>{{cite journal | vauthors = Schwartz RH, Milteer R, LeBeau MA | title = Drug-facilitated sexual assault ('date rape') | journal = Southern Medical Journal | volume = 93 | issue = 6 | pages = 558–561 | date = June 2000 | pmid = 10881768 | doi = 10.1097/00007611-200093060-00002 }}</ref><ref>{{cite journal | vauthors = Gautam L, Sharratt SD, Cole MD | title = Drug facilitated sexual assault: detection and stability of benzodiazepines in spiked drinks using gas chromatography-mass spectrometry | journal = PLOS ONE | volume = 9 | issue = 2 | article-number = e89031 | date = 2014-02-19 | pmid = 24586489 | pmc = 3929633 | doi = 10.1371/journal.pone.0089031 | doi-access = free | bibcode = 2014PLoSO...989031G }}</ref>
{{TOC limit}}

==Use==
[[File:Rohypnol.jpg|thumb|right|200px|Rohypnol 1 mg tablets.]]
In countries where this drug is used, it is used for treatment of severe cases of [[insomnia|sleeping problems]], and in some countries as a [[preanesthetic agent]].<ref name="NSW-PSB"/><ref name=Japan/> These were also the uses for which it was originally studied.<ref>{{cite journal | vauthors = Mattila MA, Larni HM | title = Flunitrazepam: a review of its pharmacological properties and therapeutic use | journal = Drugs | volume = 20 | issue = 5 | pages = 353–374 | date = November 1980 | pmid = 6108205 | doi = 10.2165/00003495-198020050-00002 | s2cid = 25151953 }}</ref>

It has also been administered as a concurrent dose for patients that are taking [[ketamine]]. Flunitrazepam lowers the side effects of the anesthetic (ketamine), resulting in less confusion in awakening states, less negative influence on pulse rate, and fewer fluctuations in blood pressure.<ref>{{cite journal | vauthors = Freuchen I, Ostergaard J, Kühl JB, Mikkelsen BO | title = Reduction of psychotomimetic side effects of Ketalar (ketamine) by Rohypnol (flunitrazepam). A randomized, double-blind trial | journal = Acta Anaesthesiologica Scandinavica | volume = 20 | issue = 2 | pages = 97–103 | date = 1976 | pmid = 7095 | doi = 10.1111/j.1399-6576.1976.tb05015.x | s2cid = 46172276 }}</ref>

==Adverse effects==
Adverse effects of flunitrazepam include dependency, both physical and psychological; reduced sleep quality resulting in [[somnolence]]; and [[overdose]], resulting in excessive sedation, impairment of balance and speech, respiratory depression or coma, and possibly death. Because of the latter, flunitrazepam is commonly used in suicide among the elderly.<ref name="Carlsten_2003">{{cite journal | vauthors = Carlsten A, Waern M, Holmgren P, Allebeck P | title = The role of benzodiazepines in elderly suicides | journal = Scandinavian Journal of Public Health | volume = 31 | issue = 3 | pages = 224–228 | year = 2003 | pmid = 12850977 | doi = 10.1080/14034940210167966 | publisher = SAGE Publications | s2cid = 24102880 }}</ref> When used in late pregnancy, it might cause [[hypotonia]] of the fetus.

===Dependence===
Flunitrazepam, as with other [[benzodiazepine]]s, can lead to [[drug dependence]].<ref name=CESAR/> Discontinuation may result in [[benzodiazepine withdrawal syndrome]], characterised by [[seizures]], [[psychosis]], insomnia, and [[anxiety (mood)|anxiety]]. [[Rebound insomnia]], worse than baseline insomnia, typically occurs after discontinuation of flunitrazepam even from short-term single nightly dose therapy.<ref>{{cite journal | vauthors = Kales A, Scharf MB, Kales JD, Soldatos CR | title = Rebound insomnia. A potential hazard following withdrawal of certain benzodiazepines | journal = JAMA | volume = 241 | issue = 16 | pages = 1692–1695 | date = April 1979 | pmid = 430730 | doi = 10.1001/jama.241.16.1692 }}</ref>

===Paradoxical effects===
Flunitrazepam may cause a [[paradoxical reaction]] in some individuals, including anxiety, [[aggressiveness]], [[Psychomotor agitation|agitation]], [[confusion]], [[disinhibition]], loss of [[impulse control]], talkativeness, [[violent]] behavior, and even [[convulsions]]. [[Paradoxical adverse effects]] may even lead to [[criminal behaviour]].<ref>{{cite journal | vauthors = Bramness JG, Skurtveit S, Mørland J | title = Flunitrazepam: psychomotor impairment, agitation and paradoxical reactions | journal = Forensic Science International | volume = 159 | issue = 2–3 | pages = 83–91 | date = June 2006 | pmid = 16087304 | doi = 10.1016/j.forsciint.2005.06.009 }}</ref>

===Hypotonia===
{{See also|Hypotonia}}
Benzodiazepines such as flunitrazepam are [[Lipophilicity|lipophilic]] and rapidly penetrate membranes and, therefore, rapidly cross over into the [[placenta]] with significant uptake of the drug. Use of benzodiazepines including flunitrazepam in late pregnancy, especially high doses, may result in [[hypotonia]], also known as floppy baby syndrome.<ref>{{cite journal | vauthors = Kanto JH | title = Use of benzodiazepines during pregnancy, labour and lactation, with particular reference to pharmacokinetic considerations | journal = Drugs | volume = 23 | issue = 5 | pages = 354–380 | date = May 1982 | pmid = 6124415 | doi = 10.2165/00003495-198223050-00002 | s2cid = 27014006 }}</ref>

===Other===
Flunitrazepam impairs cognitive functions. This may appear as lack of concentration, [[confusion]] and [[anterograde amnesia]]—the inability to create memories while under the influence. It can be described as a [[hangover]]-like effect which can persist to the next day.<ref name=Residual2004>{{cite journal | vauthors = Vermeeren A | title = Residual effects of hypnotics: epidemiology and clinical implications | journal = CNS Drugs | volume = 18 | issue = 5 | pages = 297–328 | year = 2004 | pmid = 15089115 | doi = 10.2165/00023210-200418050-00003 | s2cid = 25592318 }}</ref> It also impairs [[Psychomotor learning|psychomotor]] functions similar to other benzodiazepines and [[nonbenzodiazepine]] [[hypnotic]] drugs; falls and hip fractures were frequently reported. The combination with [[alcohol (drug)|alcohol]] increases these impairments. Partial, but incomplete tolerance develops to these impairments.<ref name="Mets-2010">{{cite journal | vauthors = Mets MA, Volkerts ER, Olivier B, Verster JC | title = Effect of hypnotic drugs on body balance and standing steadiness | journal = Sleep Medicine Reviews | volume = 14 | issue = 4 | pages = 259–267 | date = August 2010 | pmid = 20171127 | doi = 10.1016/j.smrv.2009.10.008 }}</ref>

Other adverse effects include:
* Slurred speech
* [[Gastrointestinal disturbance]]s, lasting 12 or more hours
* Vomiting
* [[Respiratory depression]] in higher doses

===Special precautions===
Benzodiazepines require special precaution if used in the elderly, during pregnancy, in children, in alcohol- or drug-dependent individuals, and in individuals with [[comorbid]] [[psychiatric disorders]].<ref>{{cite journal | vauthors = Authier N, Balayssac D, Sautereau M, Zangarelli A, Courty P, Somogyi AA, Vennat B, Llorca PM, Eschalier A | display-authors = 6 | title = Benzodiazepine dependence: focus on withdrawal syndrome | journal = Annales Pharmaceutiques Françaises | volume = 67 | issue = 6 | pages = 408–413 | date = November 2009 | pmid = 19900604 | doi = 10.1016/j.pharma.2009.07.001 }}</ref>

Impairment of driving skills with a resultant increased risk of [[road traffic accidents]] is probably the most important adverse effect. This side-effect is not unique to flunitrazepam but also occurs with other hypnotic drugs. Flunitrazepam seems to have a particularly high risk of road traffic accidents compared to other hypnotic drugs. Extreme caution should be exercised by drivers after taking flunitrazepam.<ref>{{cite journal | vauthors = Gustavsen I, Bramness JG, Skurtveit S, Engeland A, Neutel I, Mørland J | title = Road traffic accident risk related to prescriptions of the hypnotics zopiclone, zolpidem, flunitrazepam and nitrazepam | journal = Sleep Medicine | volume = 9 | issue = 8 | pages = 818–822 | date = December 2008 | pmid = 18226959 | doi = 10.1016/j.sleep.2007.11.011 | hdl-access = free | hdl = 10852/34650 }}</ref><ref name=UKdrivingregs2014>UK Dept. of Transport. July 2014. {{cite web | url = https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/325275/healthcare-profs-drug-driving.pdf | title = Guidance for healthcare professionals on drug driving | work = The Department for Transport | date = 2014 | location = London }}</ref>

== Interactions ==

The use of flunitrazepam in combination with alcoholic beverages synergizes the adverse effects, and can lead to [[toxicity]] and death.<ref name=EU>{{cite web | url = http://www.emcdda.europa.eu/publications/drug-profiles/benzodiazepine | title = Benzodiazepines drug profile | date = 8 January 2015 | work = European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) }}</ref>

==Overdose==
{{See also|Benzodiazepine overdose}}
Flunitrazepam is a drug that is frequently involved in drug intoxication, including overdose.<ref>{{cite journal | vauthors = Zevzikovas A, Kiliuviene G, Ivanauskas L, Dirse V | title = [Analysis of benzodiazepine derivative mixture by gas-liquid chromatography] | journal = Medicina | volume = 38 | issue = 3 | pages = 316–320 | year = 2002 | pmid = 12474705 }}</ref><ref>{{cite journal | vauthors = Jonasson B, Saldeen T | title = Citalopram in fatal poisoning cases | journal = Forensic Science International | volume = 126 | issue = 1 | pages = 1–6 | date = March 2002 | pmid = 11955823 | doi = 10.1016/S0379-0738(01)00632-6 }}</ref> Overdose of flunitrazepam may result in excessive sedation, or impairment of balance or speech. This may progress in severe overdoses to [[respiratory depression]] or coma and possibly death. The risk of overdose is increased if flunitrazepam is taken in combination with [[Cns depressants|CNS depressants]] such as [[ethanol]] (alcohol) and [[opioid]]s. Flunitrazepam overdose responds to the [[GABAA receptor|GABA<sub>A</sub> receptor]] antagonist [[flumazenil]], which thus can be used as a treatment.

==Detection==
As of 2016, blood tests can identify flunitrazepam at concentrations of as low as 4&nbsp;nanograms per millilitre; the elimination half-life of the drug is 4–12 hours. For urine samples, metabolites can be identified for 60 hours to 28 days, depending on the dose and analytical method used. Hair and saliva can also be analyzed; hair is useful when a long time has transpired since ingestion, and saliva for workplace drug tests.<ref name=Kiss2016/>

Flunitrazepam can be measured in blood or plasma to confirm a diagnosis of poisoning in hospitalized patients, provide evidence in an impaired driving arrest, or assist in a medicolegal death investigation. Blood or plasma flunitrazepam concentrations are usually in a range of 5–20 μg/L in persons receiving the drug therapeutically as a nighttime hypnotic, 10–50 μg/L in those arrested for impaired driving and 100–1000 μg/L in victims of acute fatal overdosage. Urine is often the preferred specimen for routine substance use monitoring purposes. The presence of 7-aminoflunitrazepam, a pharmacologically active metabolite and ''in vitro'' degradation product, is useful for confirmation of flunitrazepam ingestion. In postmortem specimens, the parent drug may have been entirely degraded over time to 7-aminoflunitrazepam.<ref name="pmid17417081">{{cite journal | vauthors = Jones AW, Holmgren A, Kugelberg FC | title = Concentrations of scheduled prescription drugs in blood of impaired drivers: considerations for interpreting the results | journal = Therapeutic Drug Monitoring | volume = 29 | issue = 2 | pages = 248–60 | date = April 2007 | pmid = 17417081 | doi = 10.1097/FTD.0b013e31803d3c04 | s2cid = 25511804 }}</ref><ref name="pmid9456517">{{cite journal | vauthors = Robertson MD, Drummer OH | title = Stability of nitrobenzodiazepines in postmortem blood | journal = Journal of Forensic Sciences | volume = 43 | issue = 1 | pages = 5–8 | date = January 1998 | pmid = 9456517 | doi = 10.1520/JFS16081J}}</ref><ref>{{cite book | vauthors = Baselt R | title = Disposition of Toxic Drugs and Chemicals in Man | edition = 8th | publisher = Biomedical Publications | location = Foster City, CA | date = 2008 | pages = 633–635 }}</ref> Other metabolites include [[desmethylflunitrazepam]] and [[nifoxipam|3-hydroxydesmethylflunitrazepam]].

==Pharmacology==
The main pharmacological effects of flunitrazepam are the enhancement of [[GABA]], an [[inhibitory neurotransmitter]], at various [[GABA receptors]].<ref name=EU/>  All benzodiazepines work by enhancing the effect of GABA receptors, which, when active, allow chloride ions to enter the neuron.<ref name="tripsitter.com">{{cite web | vauthors = Santos E |title=Flunitrazepam (Rohypnol) Fact Sheet & Harm Reduction Guide |url=https://tripsitter.com/benzodiazepines/flunitrazepam/ |website=Tripsitter |date=October 13, 2022 |access-date=15 November 2023}}</ref> Negative ions such as chloride inhibit the ability of neurons to fire.  It is this stimulation of GABA receptors which is responsible for the depressant effects of benzodiazepines. Flunitrazepam shows high affinity for the α-5 subunit of the GABA-A receptor, which causes some of its unique side effects, such as amnesia.<ref name="tripsitter.com"/>

While 80% of flunitrazepam that is taken orally is absorbed, [[bioavailability]] in suppository form is closer to 50%.<ref>{{cite journal | vauthors = Cano JP, Soliva M, Hartmann D, Ziegler WH, Amrein R | title = Bioavailability from various galenic formulations of flunitrazepam | journal = Arzneimittel-Forschung | volume = 27 | issue = 12 | pages = 2383–2388 | year = 1977 | pmid = 23801 | id = rohypnol }}</ref>

Flunitrazepam has a long [[half-life]] of 18–26 hours, which means that flunitrazepam's effects after nighttime administration persist throughout the next day.<ref name=Residual2004/> This is due to the production of active metabolites. These metabolites further increase the duration of drug action compared to benzodiazepines that produce nonactive metabolites.<ref>{{cite journal | vauthors = Griffin CE, Kaye AM, Bueno FR, Kaye AD | title = Benzodiazepine pharmacology and central nervous system-mediated effects | journal = The Ochsner Journal | volume = 13 | issue = 2 | pages = 214–223 | date = 2014 | pmid = 23789008 | pmc = 3684331 }}</ref>

Flunitrazepam is lipophilic and is metabolised by the liver via oxidative pathways. The enzyme [[CYP3A4]] is the main enzyme in its [[phase 1 metabolism]] in human liver microsomes.<ref>{{cite journal | vauthors = Hesse LM, Venkatakrishnan K, von Moltke LL, Shader RI, Greenblatt DJ | title = CYP3A4 is the major CYP isoform mediating the in vitro hydroxylation and demethylation of flunitrazepam | journal = Drug Metabolism and Disposition | volume = 29 | issue = 2 | pages = 133–140 | date = February 2001 | pmid = 11159802 | url = http://dmd.aspetjournals.org/cgi/content/abstract/29/2/133 | archive-date = March 21, 2009 | access-date = November 25, 2007 | archive-url = https://web.archive.org/web/20090321141246/http://dmd.aspetjournals.org/cgi/content/abstract/29/2/133 }}</ref>

==Chemistry==
Flunitrazepam is classed as a nitro-benzodiazepine. It is the [[fluorine|fluorinated]] ''N''-methyl derivative of [[nitrazepam]]. Other nitro-benzodiazepines include nitrazepam (the parent compound), [[nimetazepam]] (methylamino derivative) and [[clonazepam]] (2ʹ-chlorinated derivative).<ref>{{cite journal | vauthors = Robertson MD, Drummer OH | title = Postmortem drug metabolism by bacteria | journal = Journal of Forensic Sciences | volume = 40 | issue = 3 | pages = 382–386 | date = May 1995 | pmid = 7782744 | doi = 10.1520/JFS13791J }}</ref>

Flunitrazepam has a melting point of around 170 degrees Celsius.<ref>{{cite journal |last1=Sternbach |display-authors=etal |first1=L. |title=Quinazolines and 1,4-Benzodiazepines. X.1 Nitro-Substituted 5-Phenyl-1,4-benzodiazepine Derivatives2 |journal=Journal of Medical Chemistry |date=1 May 1963 |volume=6 |issue=3 |pages=261–265 |doi=10.1021/jm00339a010 |pmid=14185980 |url=https://pubs.acs.org/doi/abs/10.1021/jm00339a010 |access-date=15 November 2023|url-access=subscription }}</ref>

==History==
Flunitrazepam was discovered at [[Hoffmann-La Roche|Roche]] as part of the benzodiazepine work led by [[Leo Sternbach]]; the patent application was filed in 1960 and it was first marketed in 1972.<ref>
  {{cite book | vauthors = Alapi EM, Fischer J | chapter = Table of Selected Analogue Classes | veditors = Fische J, Ganellin CR|title=Analogue-Based Drug Discovery |date=2006 |publisher=Wiley-VCH |location=Weinheim |isbn=978-3-527-60749-5 | page = [https://books.google.com/books?id=FjKfqkaKkAAC&pg=PA537 537] }}
</ref>
<ref>
  {{cite journal | vauthors = Bryan J | title = Landmark drugs: The discovery of benzodiazepines and the adverse publicity that followed. | journal = The Pharmaceutical Journal | date = September 2009 | volume = 283 | page = 305 | url = http://www.pharmaceutical-journal.com/opinion/comment/landmark-drugs-the-discovery-of-benzodiazepines-and-the-adverse-publicity-that-followed/10978453.article | archive-url = https://web.archive.org/web/20151120033823/http://www.pharmaceutical-journal.com/opinion/comment/landmark-drugs-the-discovery-of-benzodiazepines-and-the-adverse-publicity-that-followed/10978453.article | archive-date = 20 November 2015 }}
</ref>

Due to use of the drug for [[date rape drug|date rape]] and recreation, in 1998 Roche modified the formulation to give lower doses, make it less soluble, and add a blue dye for easier detection in drinks.<ref name=Kiss2016>{{cite book | vauthors = Kiss B, Bodoki E, Pop A, Loghin F | chapter = Chapter 48: Assays for Flunitrazepam | veditors = Preedy VR |title=Neuropathology of drug addictions and substance misuse. Volume 2, Stimulants, club and dissociative drugs, hallucinogens, steroids, inhalants, and international aspects |date=2016 |location=London | publisher = Academic Press |isbn=978-0-12-800375-6 | chapter-url = https://books.google.com/books?id=zu5eBwAAQBAJ&pg=PA513 | page = 513}}</ref> It was never marketed in the United States, and by 2016 had been withdrawn from the markets in Spain, France, Norway, Germany, and the United Kingdom.<ref name=Kiss2016/>

==Society and culture==

===Recreational and illegal uses===
[[File:Hypnodorm.jpg|thumb|Hypnodorm 1 mg flunitrazepam tablets, Australia]]
[[File:rohypnol2.jpg|thumb|Rohypnol]]

====Recreational use====
A 1989 article in the ''[[European Journal of Clinical Pharmacology]]'' reports that benzodiazepines accounted for 52% of prescription forgeries in [[Sweden]], suggesting that benzodiazepines were a major prescription drug class of abuse. [[Nitrazepam]] accounted for 13% of forged prescriptions, and accounted for 44% of forgeries specifically for benzodiazepines while flunitrazepam, diazepam, and oxazepam accounted for the majority of the rest of benzodiazepine forgeries. Prescription forgeries for other benzodiazepines marketed in Sweden (alprazolam, clonazepam, lorazepam, clobazam, and bromazepam) were negligible. When calculated in relation to utilization, the narcotic analgesics codeine, pentazocine, and ketobemidone were at the top of the list for the highest number of overall prescription forgeries, suggesting a higher abuse potential of these drugs.<ref>{{cite journal | vauthors = Bergman U, Dahl-Puustinen ML | title = Use of prescription forgeries in a drug abuse surveillance network | journal = European Journal of Clinical Pharmacology | volume = 36 | issue = 6 | pages = 621–623 | date = November 1989 | pmid = 2776820 | doi = 10.1007/BF00637747 | s2cid = 19770310 }}</ref> In neighboring [[Finland]], temazepam accounts for roughly 40–50% benzodiazepine prescription forgeries annually, while flunitrazepam accounts for approximately ~15% of benzodiazepine prescription forgeries.<ref name="Europedrugs">{{cite web|title=Classification of controlled drugs|url=http://www.emcdda.europa.eu/html.cfm/index146601EN.html|publisher=EMCDDA|access-date=30 June 2022}}</ref>

Flunitrazepam and other sedative hypnotic drugs are detected frequently in cases of people suspected of driving under the influence of drugs. Other benzodiazepines and nonbenzodiazepines ([[anxiolytic]] or [[hypnotic]]) such as [[zolpidem]] and [[zopiclone]] (as well as [[cyclopyrrolones]], [[imidazopyridine]]s, and [[pyrazolopyrimidine]]s) are also found in high numbers of suspected drugged drivers. Many drivers have blood levels far exceeding the therapeutic dose range, suggesting a high degree of [[abuse potential|potential for addiction]] for benzodiazepines and similar drugs.<ref>{{cite journal | vauthors = Jones AW, Holmgren A, Kugelberg FC | title = Concentrations of scheduled prescription drugs in blood of impaired drivers: considerations for interpreting the results | journal = Therapeutic Drug Monitoring | volume = 29 | issue = 2 | pages = 248–260 | date = April 2007 | pmid = 17417081 | doi = 10.1097/FTD.0b013e31803d3c04 | s2cid = 25511804 }}</ref>

====Suicide====
In studies in Sweden, flunitrazepam was the second most common drug used in suicides, being found in about 16% of cases.<ref>{{cite journal | vauthors = Jonasson B, Jonasson U, Saldeen T | title = Among fatal poisonings dextropropoxyphene predominates in younger people, antidepressants in the middle aged and sedatives in the elderly | journal = Journal of Forensic Sciences | volume = 45 | issue = 1 | pages = 7–10 | date = January 2000 | pmid = 10641912 | doi = 10.1520/JFS14633J }}</ref> In a retrospective Swedish study of 1,587 deaths, in 159 cases benzodiazepines were found. In suicides when benzodiazepines were implicated, the benzodiazepines flunitrazepam and nitrazepam occurred in significantly higher concentrations compared to natural deaths. Of the 159 deaths where any benzodiazepines were found, 4 deaths were caused by benzodiazepines alone (in the other 155 cases, benzodiazepines were combined with something else). One conclusion of the study was that flunitrazepam and nitrazepam might be more toxic than other benzodiazepines available in the Swedish market.<ref>{{cite journal | vauthors = Ericsson HR, Holmgren P, Jakobsson SW, Lafolie P, De Rees B | title = [Benzodiazepine findings in autopsy material. A study shows interacting factors in fatal cases] | journal = Läkartidningen | volume = 90 | issue = 45 | pages = 3954–3957 | date = November 1993 | pmid = 8231567 }}</ref><ref>{{cite journal | vauthors = Drummer OH, Syrjanen ML, Cordner SM | title = Deaths involving the benzodiazepine flunitrazepam | journal = The American Journal of Forensic Medicine and Pathology | volume = 14 | issue = 3 | pages = 238–243 | date = September 1993 | pmid = 8311057 | doi = 10.1097/00000433-199309000-00012 | s2cid = 28937806 }}</ref>

====Drug-facilitated sexual assault====
{{Main|Drug facilitated sexual assault}}
Flunitrazepam is known to induce [[anterograde amnesia]] in sufficient doses; individuals are unable to remember certain events that they experienced while under the influence of the drug, which complicates investigations.<ref>{{cite news | vauthors = Liljesson S | date = 3 June 1999 |url= http://drugnews.nu/article.asp?id=199 |title=Bankrånare stärkte sig med Rohypnol?|publisher=DrugNews |access-date=May 19, 2006|archive-url= https://web.archive.org/web/20070929165033/http://drugnews.nu/article.asp?id=199|archive-date=September 29, 2007}}</ref><ref>{{cite news|url=http://www.expressen.se/index.jsp?d=737&a=116288|title=Mijailovic var påverkad av våldsdrog|newspaper=Expressen}}</ref>  This effect could be particularly dangerous if flunitrazepam is used to aid in the commission of [[sexual assault]]; victims may be unable to clearly recall the assault, the assailant, or the events surrounding the assault.<ref name=Kiss2016/>

While use of flunitrazepam in sexual assault has been prominent in the media, as of 2015 it appears to be fairly rare, and use of alcohol and other benzodiazepine drugs in date rape appears to be a larger but underreported problem.<ref name=EU/>

In a 2001 study, the benzodiazepines [[midazolam]] and [[temazepam]] were the two most common benzodiazepines utilized for date rape.<ref>{{cite book | vauthors = El-Sohly MA, Lee LF, Holzhauer LB, Salamone SJ | editor-first1 = Salvatore J. | editor-last1 = Salamone | chapter = Analysis of Urine Samples in Cases of Alleged Sexual Assault | title = Benzodiazepines and GHB | series = Forensic Science and Medicine | year = 2001 | pages = 127–144 | publisher = Humana Press |doi=10.1007/978-1-59259-109-1 |isbn=1-59259-109-4 |chapter-url = https://link.springer.com/chapter/10.1007/978-1-59259-109-1_7}}</ref>

====Drug-facilitated robbery====
In the United Kingdom, the use of flunitrazepam and other "date rape" drugs have also been connected to stealing from sedated victims. An activist quoted by a British newspaper estimated that up to 2,000 individuals are robbed each year after consuming drinks spiked with powerful sedatives,<ref>{{cite news| url=https://www.theguardian.com/crime/article/0,2763,1376956,00.html |work=The Guardian |location=London |title='Rape drug' used to rob thousands | vauthors = Thompson T |date=December 19, 2004 |access-date=May 2, 2010}}</ref> making drug-assisted robbery a more commonly reported problem than drug-assisted rape.

===Regional use===
Flunitrazepam is a [[Convention on Psychotropic Substances#Schedules of Controlled Substances|Schedule III]] drug under the international [[Convention on Psychotropic Substances]] of 1971.<ref>{{cite web | publisher = International Narcotics Control Board | url = http://www.incb.org/documents/Psychotropics/greenlist/Green_list_ENG_2015_new.pdf | title = List of Psychotropic Substances under International Control | archive-url = https://web.archive.org/web/20170713091834/http://www.incb.org/documents/Psychotropics/greenlist/Green_list_ENG_2015_new.pdf | archive-date= 13 July 2017 | work = Green List | edition = 26th | date = 2015 }}</ref>
* In Australia, as of 2013 the drug was authorized for prescribing for severe cases of insomnia but was restricted as a [[Standard for the Uniform Scheduling of Drugs and Poisons|Schedule 8]] medicine.<ref name="NSW-PSB"/><ref name="DoHWesternAustralia">{{cite web| date= August 13, 2004| url= http://www.health.wa.gov.au/notifications/authorisations/drugs/flunitrazepam.cfm| title= Authorisation to Supply or Prescribe Drugs of Addiction: Flunitrazepam| work= Statutory Medical Notifications| publisher= Department of Health, Government of Western Australia| access-date= 2006-03-13| archive-url = https://web.archive.org/web/20060828184311/http://www.health.wa.gov.au/notifications/authorisations/drugs/flunitrazepam.cfm <!-- Bot retrieved archive --> |archive-date = August 28, 2006}}</ref>
* In France, as of 2016 flunitrazepam was not marketed.<ref name=Kiss2016/>
* In Germany, as of 2016 flunitrazepam is an ''[[Anlage III]] Betäubungsmittel'' (controlled substance which is allowed to be marketed and prescribed by physicians under specific provisions) and is available on a special narcotic drug prescription as the Rohypnol 1&nbsp;mg film-coated tablets and several generic preparations (November 2016).<ref>{{Cite web|url=https://www.gelbe-liste.de/wirkstoffe/flunitrazepam_2624|title = Flunitrazepam - Anwendung, Wirkung, Nebenwirkungen | work = Gelbe Liste | publisher = Vidal MMI Germany GmbH |last1 = Online |first1 = Gelbe Liste }}</ref>
* In Ireland, flunitrazepam is a Schedule 3 controlled substance with strict restrictions.<ref>{{cite web | url = http://www.irishstatutebook.ie/1993/en/si/0342.html | work = Irish Statute Book, Statutory Instruments | title = S.I. No. 342/1993 — Misuse of Drugs (Amendment) Regulations | date = 1993 }}</ref>
* In Japan, flunitrazepam is marketed by Japanese pharmaceutical company [[Chugai Pharmaceutical Co.|Chugai]] under the trade name Rohypnol and is indicated for the treatment of insomnia as well as used for preanesthetic medication.<ref name=Japan>{{cite web |url=http://www.rad-ar.or.jp/siori/english/kekka.cgi?n=1051 |title=Kusuri-no-Shiori Drug Information Sheet |date=October 2015 |publisher=RAD-AR Council, Japan |access-date=2016-06-13 |archive-date=March 3, 2016 |archive-url=https://web.archive.org/web/20160303232158/http://www.rad-ar.or.jp/siori/english/kekka.cgi?n=1051 }}</ref>
* In Mexico, Rohypnol is legally available.<ref>{{cite web |title=What is Rohypnol? |url=https://www.12southrecovery.us/post/what-is-rohypnol |website=12 South Recovery |date=May 27, 2019 |access-date=24 January 2021}}</ref>
* In Norway, on January 1, 2003, flunitrazepam was moved up one level in the schedule of controlled drugs and, on August 1, 2004, the manufacturer Roche removed Rohypnol from the market there altogether.<ref>{{cite journal | vauthors = Bramness JG, Skurtveit S, Furu K, Engeland A, Sakshaug S, Rønning M | title = [Changes in the sale and use of flunitrazepam in Norway after 1999] | journal = Tidsskrift for den Norske Laegeforening | volume = 126 | issue = 5 | pages = 589–590 | date = February 2006 | pmid = 16505866 }}</ref>
*In South Africa, Rohypnol is classified as a Schedule 6 drug.<ref name="RohypnolSA">{{cite web| date= October 11, 2006| url= http://www.drugaware.co.za/rohypnol.html | title = Rohypnol | work = Drug Wars – About Drugs}}</ref> It is available by prescription only, and restricted to 1&nbsp;mg doses.

[[File:Iceland Flunitrazepam Mylan 1mg.png|thumb|155x155px|Icelandic Flunitrazepam]]

* In Iceland, flunitrazepam is a controlled substance available from [[Mylan]]. It is prescribed for severe insomnia and is sometimes used before surgery to induce a calm, relaxed state of mind for the patient.<ref>{{Cite web|url=https://www.lyfja.is/lyfjabokin/lyf/FlunitrazepamMylan|title=Flunitrazepam Mylan|website=Lyfja - Lifið heil|language=is|access-date=2020-02-27|archive-date=February 27, 2020|archive-url=https://web.archive.org/web/20200227001722/https://www.lyfja.is/lyfjabokin/lyf/FlunitrazepamMylan|url-status=dead}}</ref>
* In Sweden, flunitrazepam is a List II drug (substances with medicinal uses) under the Narcotics Control Act (1968).<ref>{{cite web |url=https://www.lakemedelsverket.se/sv/sok-lakemedelsfakta/substans?id=E4POCOU9OKGVERT1 |title=Flunitrazepam |publisher=Medical Products Agency |access-date=February 17, 2022 |location=Sweden |language=Swedish}}</ref> It was previously available from Mylan,<ref>{{Cite web|url=http://www.fass.se/LIF/produktfakta/substance_products.jsp?substanceId=IDE4POCOU9OKGVERT1|title = Substans | work = Farmaceutiska Specialiteter i Sverige (FASS) Allmänhet}}</ref> but has been removed from the market in January 2020.<ref>{{Cite web | url = https://janusinfo.se/nyheter/nyheter/2019/flunitrazepamutgar.5.1902def216e9304699285304.html | title = Flunitrazepam utgår | trans-title = Flunitrazepam is discontinued | work = Janusinfo | location = Stockholm | language = Swedish | access-date = August 30, 2021 | archive-date = August 30, 2021 | archive-url = https://web.archive.org/web/20210830111722/https://janusinfo.se/nyheter/nyheter/2019/flunitrazepamutgar.5.1902def216e9304699285304.html }}</ref>
* In the United Kingdom, flunitrazepam is not licensed for medical use<ref name="UKdrivingregs2014" /><ref name="Kiss2016" /> and is a controlled drug under [[Controlled Drug in United Kingdom#Schedule 3 - CD No Reg|Schedule 3]] and [[Drugs controlled by the UK Misuse of Drugs Act#Class C drugs|Class C]].<ref>{{cite web | url = https://www.gov.uk/government/publications/controlled-drugs-list--2/list-of-most-commonly-encountered-drugs-currently-controlled-under-the-misuse-of-drugs-legislation | title = List of most commonly encountered drugs currently controlled under the misuse of drugs legislation | date = 8 August 2022 | work = Gov.uk }}</ref>
* In the United States, the drug has not been approved by the [[Food and Drug Administration (United States)|Food and Drug Administration]] and is considered to be an [[illegal drug]]; as of 2016 it is [[Controlled Substances Act#Schedule IV controlled substances|Schedule IV]].<ref name="Kiss2016" /><ref>DEA [Lists of Scheduling Actions Controlled Substances Regulated Chemicals May 2016]</ref> {{UnitedStatesCode|21|841}} and {{UnitedStatesCode|21|952}} provide for punishment for the importation and distribution of up to 20 years in prison and a fine; possession is punishable by three years and a fine.<ref name="CESAR">{{cite web | work = Center for Substance Abuse Research | publisher = University of Maryland | url = http://www.cesar.umd.edu/cesar/drugs/rohypnol.asp | title = Flunitrazepam (Rohypnol) | archive-url = https://web.archive.org/web/20160109205146/http://www.cesar.umd.edu/cesar/drugs/rohypnol.asp | archive-date= January 9, 2016 | date = 29 October 2013 }}</ref> Travelers travelling into the United States are limited to a 30-day supply. The drug must be declared to [[US Customs]] upon arrival. If a valid prescription cannot be produced, the drug may be subject to Customs [[search and seizure]], and the traveler may face criminal charges or deportation.

===Names===
Flunitrazepam is marketed under many brand names in the countries where it is legal.<ref name=generics>{{cite web | work = Drugs.com  | url = https://www.drugs.com/international/flunitrazepam.html | title = International brands for Flunitrazepam | access-date = 13 April 2016 }}</ref> It also has many street names, including "roofie" and "ruffie".<ref name=CESAR/> It is also known as Circles, Forget Me Pill, La Rocha, Lunch Money Drug, Mexican Valium, Pingus, R2, and Roach 2.<ref>{{cite web |title=Rohypnol |url=https://www.dea.gov/factsheets/rohypnol |website=United States Drug Enforcement Administration |access-date=October 18, 2020}}</ref>

== References ==
{{Reflist}}

== External links ==
{{Commons category|Flunitrazepam}}

{{Benzodiazepines}}
{{Hypnotics and sedatives}}
{{GABAAR PAMs}}
{{Glycinergics}}
{{Authority control}}

[[Category:GABAA receptor positive allosteric modulators]]
[[Category:Glycine receptor antagonists]]
[[Category:Designer prodrugs]]
[[Category:Drugs developed by Hoffmann-La Roche]]
[[Category:Lactams]]
[[Category:Nitrobenzodiazepines]]
[[Category:2-Fluorophenyl compounds]]
[[Category:Drug culture]]
[[Category:Drug-facilitated sexual assault]]
[[Category:Hypnotics]]