Last week, Dr Chris Luke wrote in The Journal about why suspected cases of drink spiking can sometimes go unheeded by medics in emergency departments. This week, he shares his thoughts on a new approach that he says is needed to tackle the problem. 

IN MY PREVIOUS article about so-called ‘date rape drugs’, I explained how I’d been persuaded that the scepticism of some frontline clinicians towards a complaint of ‘I think my drink was spiked’ was no longer justifiable.

I explained that the scepticism originated in the sheer scale of recreational intoxication that staff have to deal with, in every urban emergency department, especially at weekends, plus the dearth of substantial medical research proving the intentional ‘spiking’ of people’s drinks.

But what had altered my view radically (after many years’ working in emergency medicine) was a recent series of court cases in England, Scotland and France involving hundreds of cases of ‘drug-facilitated sexual assault’ (DFSA), where convictions were secured not by medical tests, but by CCTV and phone camera footage of the actual acts of ‘spiking’ and subsequent assaults.

The scale of harm was devastating. In a few cases, it was lethal, and in most cases, it took years to be recognised. That is why I am convinced that a new approach is now required.

So what should we do about ‘spiked drinks’?

Take it seriously

Firstly, we must take the issue more seriously. Experience teaches us that it is sometimes only the catastrophic consequences of ‘drink spiking’ (death or acquisition of HIV) that convinces people that ‘spiking’ is not an urban myth.

Now, we can refer to a growing ‘panel’ of precedents proving that the issue is devastatingly real, and ‘ordinary-looking’ perpetrators may get away with repeated attacks because of the victims’ shame, amnesia (a common feature of almost all drugs used to incapacitate) or ‘gaslighting’. Like in France, where Gisèle Pelicot’s husband convinced her she was suffering from brain failure when she ‘sort of’ recalled frightening memories’. The issue of ‘drink spiking’ is real, and the state is failing to protect victims.

Drink spiking is extraordinarily dangerous for various reasons, and death is a real risk.

This could be due to an overdose of the agent (GHB – or gamma-hydroxybutyrate – is a drug that can easily kill if not given in the correct dosage; with a pipette, for instance); due to assault while incapacitated; due to asphyxiation (for instance, inhaling vomit); or due to an ‘accident’ (for instance, staggering into traffic while confused or falling off a balcony). Other risks include sublethal injury, sexual trauma, transmission of diseases like HIV, chlamydia or gonorrhoea, and post-traumatic stress disorder.

Know the signs

Medical experience tells us that the current approach may be ‘pragmatic’, but it is far from perfect, and the obvious scepticism of some clinicians may deter real victims from seeking help.

We need to keep educating people about the way drink ‘spiking’ may present.

This can be with sudden subjective symptoms like extreme dizziness, drowsiness or disorientation, feeling faint or nauseated and collapse (out of all proportion to the known consumption of a drug or drink); with memory gaps or blackouts that can be profound due either to alcohol but also GHB or medicines like the sleeping tablet Lorazepam; with a weird sense of being detached from one’s body, unable to move or speak normally, a mounting panic or sense of unreality (classically with Ketamine, a popular drug at music festivals); or in someone who ‘can normally hold their drink’, a drink that had tasted bitter or otherwise odd and they really hadn’t consumed more than their ‘usual amount’ of alcohol. 

The visible manifestations – or signs – of spiking include unusual behaviour, slurred speech, collapse or someone acting suspiciously near the victim’s drink, especially in a venue known for such incidents. It is also important to appreciate that the main reasons for people looking ‘acutely unwell’ (or ‘out of it’) include consuming more alcohol than is wise, mixing alcohol with prescription medications, low blood sugar, dehydration, or anxiety/panic attacks following too many energy drinks.

Alcohol is one of the most commonly-used drugs in drink ‘spiking’. In the vast majority of cases, it is the easiest incapacitant to obtain and the hardest to prove it was maliciously used.

Others that are commonly-used include GHB, Benzodiazepines like Lorazepam, ‘Z drugs’ (like the sleeping medication, Zopiclone), antihistamines and opiates. These are all useful for sedating, producing incoordination and amnesia, and many are eliminated from the bloodstream before they can be detected. For example, urinary GHB is usually only detectable for 12 hours. 

Needle spiking – or ‘needling’ – involves injury (usually to a limb, in a crowded venue) which, like suspected ‘spiking’, should be treated on its own merits and photographed for the record. Uneventful physical recovery is the norm, and poisoning is rare, but the victim can be emotionally traumatised for a long time afterward. Even more research is needed regarding this type of assault, which has featured in a growing number of recent complaints to An Garda Síochána.

Testing facility

It may be that a dedicated service is required for suspected cases of spiking. This could be a centralised facility in each city or county, where samples from the victim (and ideally whatever they may have consumed) are obtained, separately from any immediate care, and subsequent clinical follow-up and testing can be provided. Most victims of suspected spiking can be observed routinely for a period of hours in an Emergency Department before onward referral to such a facility.

An obvious source of advice here would be the experts within our sexual assault treatment units (SATUs) or Rape Crisis Centres, who have immense experience dealing with traumatised people away from the unsuitable environment of a noisy, hectic and crowded emergency department, and they are likely to have much to say that is useful in the development of workable protocols.

It is also important to remember that clubs, pubs and event venues have a primary role in preventing and responding to drink spiking and needling.

Ultimately, they have a clear responsibility for their customers’ welfare, which means they need to keep their clientele safe and protected from assault, poisoning or mishaps. This obviously means employing suitably trained staff at the doors, counters, rest rooms and so forth. But in larger venues, appropriate first aid training is essential, along with a medical (recovery) room and records, adequately maintained and monitored CCTV cameras with recordings that are kept for potential forensic examination subsequently.

Prevention methods

Initiatives that are of marginal ‘scientific’ value, like bag searches, bracelet testing strips that identify if GHB or Ketamine have been put into a drink, or rubber caps for bottles and glasses, may not demonstrably eliminate ‘spiking’, but they can act as useful reminder to staff and customers to be wary of the dangers of somebody popping a liquid (like that illicit ‘double shot’) or soluble pill into a drink.

All clubs should also have close working relationships with their local healthcare professionals and police to share ‘intelligence’ on near-misses or confirmed incidents, and to keep up to date with the endlessly varying substances being taken or given, in and around places where people come to have fun.

Finally, it seems to me that ‘the future of the forensics’ when it comes to drink spiking will be digital. Smartphone and CCTV recordings, online displays and sharing of maliciously-obtained images, and technology like facial recognition for identifying suspicious activity in clubs and pubs are far more likely to yield results in terms of deterrence and criminal prosecution than medical protocols or testing.

The primary purpose of emergency care will always be to prevent and mitigate medical harm, and even if toxicology testing is done more frequently, it will still not add much to the criminal or preventive processes in the places where people actually have their drinks ‘spiked’.

Of course, the future of useful information is already online, and everyone should read the Spiking section on the HSE’s website. 

Dr Chris Luke is a retired Consultant in Emergency Medicine and host of the Irish Medical Lives podcast.