Legal Medicine 9 (2007) 192–195

www.elsevier.com/locate/legalmed

Case Report

Drug facilitated sexual assault using an over-the-counter ocular

solution containing tetrahydrozoline (VisineÒ)
a,*
Henry A. Spiller , Jacqualine Rogers b, Tama S. Sawyer c

a
Kentucky Regional Poison Center, Louisville, KY, USA
b
Kentucky State Police, Electronic Crime Branch, Frankfort, KY, USA
c
Mid-America Poison Center, Kansas City, KS, USA

Received 19 October 2006; received in revised form 12 January 2007; accepted 15 January 2007
Available online 22 February 2007

Abstract

Drug facilitated sexual assault (DFSA) has been defined as sexual activity occurring where consent is invalid or absent due to the
effects of drugs and or alcohol. We report the use of a commonly available over-the-counter drug to induce an obtunded compliant
victim with no memory of the period during the sexual assault. An adult male repeatedly used tetrahydrozoline to induce a comatose
state in an adult female and four female children for the purposes of sexual assault. It may be warranted to include imidazoline
derivatives in the testing for cases of DFSA.
Ó 2007 Elsevier Ireland Ltd. All rights reserved.

Keywords: Drug-facilitated sexual assault; Tetrahydrozoline; Imidazoline

1. Introduction medication that has not previously been reported in DFSA

Drug facilitated sexual assault (DFSA) has been defined
as sexual activity occurring where consent is invalid or
absent due to the effects of drugs and or alcohol [1]. Often
a second component of DFSA is use of substances to
impair the victim’s memory or production of a period of
unconsciousness, so that victims are less able to accurately
recall the circumstances or resist the attacker [2]. The true
incidence of sexual assault involving malicious administra-
tion of a drug is unknown but appears to be uncommon
[1,3–5]. However, the incidence of DFSA may be increasing
[6]. In the majority of cases the primary intoxicant appears
to be alcohol, a benzodiazepine or another hypnotic [3,5,7].
However, use of other substances to incapacitate victims
has been reported [8–10].
This report presents a case of drug facilitated sexual
assault involving a commonly available over-the-counter
*
Corresponding author. Tel.: +1 502 629 5326; fax: +1 502 629 7277.
E-mail address: henry.spiller@nortonhealthcare.org (H.A. Spiller).
and may not be part of the substances tested for after
suspected DFSA.
2. Case report
In 2003 investigation by a police Crimes Against Chil-
dren unit located pictorial evidence on the Internet of
adults having sex with children. Continued investigation
located an address believed to be associated with the pro-
vider of the pictorial images. Upon arrival at this location
there was an unanticipated discovery of the 4 children in
the pictures. The children were immediately removed from
the home.
At the home were an adult male relative (uncle) with
sole legal custody of the children and four female children,
ages 2 years old through 8 years old. Subsequent investiga-
tion located an adult female, who was the estranged wife of
the adult male, was not related to the children and was no
longer living at the location. Further inquiry suggested
the wife may have left prior to when the sexual abuse of
the children began.

1344-6223/$ - see front matter Ó 2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.legalmed.2007.01.005
 H.A. Spiller et al. / Legal Medicine 9 (2007) 192–195
Upon return to the home with a search warrant, it was
found that all computer, video and camera equipment
had been removed prior to the return. Pictures and videos
of the adult male having sex with his apparently uncon-
scious wife were confiscated.
After being removed from the home the children were
interviewed and entered into counseling. Additionally the
estranged wife was later interviewed as well. The following
history was obtained.
2.1. Sexual abuse of the adult female
The adult male was physically and verbally abusive to
his wife prior to her leaving. The wife reported, shortly
before her leaving the marriage, having found pictures
of herself asleep, involved in sexual activities with her
estranged husband for which she had no memory. She
denied knowledge of the videos that had been confiscated
during the police search or the acts performed in the
videos, which showed her deeply obtunded having non-
consensual sex with her only response being occasional
non-purposeful moans. Additionally, shortly before the
estranged wife left, the family was taken on a camping trip.
While at the camp site the adult male offered to prepare an
alcoholic beverage. While he was fixing the drink she
walked up behind him unannounced and after being star-
tled he quickly placed an item in his pocket. She questioned
him and eventually he presented a bottle of VisineÒ, an
over-the-counter ocular medication, from his shirt pocket.
She was convinced he was placing something from the
VisineÒ bottle in her drink. Shortly after this incident the
wife left the home, leaving the girls with their uncle. She
further stated her estranged husband constantly kept a
bottle of VisineÒ on his person. The estranged wife
reported when she left the home her husband had cameras,
video equipment and computers in the home, none of
which were located when the police had returned with a
search warrant.
2.2. Sexual abuse of the children
The uncle was physically and verbally abusive to the
children, including controlled access to food which was
kept under lock and key. The children, ages 2 through
8, described a pattern of when they were ‘‘bad’’ they
would get very little to eat the day they were to be
‘‘punished’’. Then they would be given a drink that tast-
ed ‘‘old’’. The older children reported being told this
drink was so they would not remember their punishment.
Following the drink, they would ‘‘sleep’’ until late in the
following day. They reported waking up after lunch time
the following day, feeling nauseous and ‘‘sore’’. The
children reported no memory of the acts depicted in
the photographs. The older children also reported mem-
ories of camera, video and computer equipment in the
home, none of which was found when the search was
executed on the home. The estranged wife stated she
193
believed the substance in the drink given to the children
was VisineÒ.
3. Discussion
VisineÒ contains 0.05% tetrahydrozoline (500 lg/ml),
an a-agonist, with similar properties to other imidazoline
derivatives, such as clonidine, tizanidine or naphazoline.
Clinical effects from ingestion of tetrahydrozoline include
drowsiness, coma, respiratory depression, bradycardia,
hypotonia, muscle flaccidity and hypothermia [11–16].
Stimulation of pre-synaptic a2 receptors decreases pro-
duction of cyclic AMP and therefore a decrease in neu-
ron activity. In the Vasomotor center a2 stimulation
inhibits sympathetic outflow to the cardiovascular sys-
tem. In the locus coeruleus, a2 stimulation produces
the opiate-like effects of CNS depression, constricted
pupils and depression of respiratory drive. a2 receptor
stimulation in the spinal cord reduces excitation of
spinal cord interneurons, preventing release of excitatory
amino acids (glutamate), producing hypotonia and
muscle flaccidity.
Ingestion of tetrahydrozoline would produce an obtun-
ded, flaccid victim unable to resist or recall events that
occurred during the periods of coma, effects consistent with
the histories reported by the children and the adult female
in this report. The dose necessary to produce coma in a
child has been reported as 2–5 ml of a 0.05% solution
[11–13]. The dose to produce coma in an adult is unclear,
but 30 ml of a 0.05% solution produced hypothermia, bra-
dycardia, hypotension and light coma in an adult male [16].
Like most drugs used in DFSA, mixing an imidazoline,
such as tetrahydrozoline, with alcohol is likely to potenti-
ate the CNS depressant effects. This synergistic effect may
have been used in the adult female of this report. It is
unclear where the adult male learned of the potential effects
of tetrahydrozoline. However, in one reported case of an
adult male attempting suicide with tetrahydrozoline, when
asked why he chose VisineÒ he stated he learned of its
effects from prostitutes and bartenders who used it to
subdue rowdy customers [16].
The onset of action after ingestion of tetrahydrozoline is
rapid, from 15 to 30 min [12,14–16]. This rapid onset is a
similar profile to other drugs used in DFSA [17]. The
duration of action is reported as from 12 to 24 h, after
ingestion [12,15,16]. This long duration is consistent with
the histories given by the children and the adult female in
this report.
Finally, while this is the first report of the use of
tetrahydrozoline for DFSA, others have suggested another
imidazoline (clonidine) be included in the list of drugs
screened for specimens collected from victims of DFSA
[9,18]. Clinical effects after overdose of all of the imidazo-
lines are similar and any would potentially be a candidate
for misuse in DFSA [19–24]. As shown in Table 1 the
imidazoline derivatives are widely available as both
over-the-counter and prescription uses.
194 H.A. Spiller et al. / Legal Medicine 9 (2007) 192–195

Table 1
Available imidazoline derivatives with a-agonist properties
Drug Availability Brand names Dose available Expected/prescribed use
Tetrahydrozoline Over the counter Collyrium Fresh Eye Drops 0.05% (500 lg/ml) Ophthalmic solution –
Geneye Eye DropsÒ conjunctivitis (red irritated
Geneye ExtraÒ eyes)
Murine PlusÒ
Optigene 3
Tertasine
Tetrasine ExtraÒ
VisineÒ
Vsion Eye SolutionÒ
Xylometazoline Over the counter Otrivin Ped. NasalÒ 0.05% (500 lg/ml) to Nasal decongestant
OtrivinÒ 0.1% (1 mg/ml)
Natru-ventÒ
Naphazoline Over the counter 20/20 Eye DropsÒ 0.012% (120 lg/ml) Ophthalmic solution –
All ClearÒ 0.03% (300 lg/ml) conjunctivitis (red irritated
Clear EyesÒ eyes)
NaphconÒ
VasoclearÒ
All Clear ARÒ
Comfort Eye DropsÒ
Naphazoline Prescription AK-ConÒ 0.1% (1 mg/ml) Ophthalmic solution –
AlbalonÒ conjunctivitis (red irritated
Nafazair eyes)
Naphcon Forte
Oxymetazoline Over the counter 12 Hour NasalÒ 0.025% (250 lg/ml) to Nasal decongestant,
Neo-synephrine 12-HourÒ 0.05% (500 lg/ml) ophthalmic solution –
DurationÒ conjunctivitis (red irritated
Afrin 12 hourÒ eyes)
Dristan 12-Hr NasalÒ
Duramist Plus 12 Hr Nostrilla 12 HourÒ
Vicks Sinex 12 Hr
LAÒ
OcuClear
Visine LRÒ
Clonidine Prescription Catapres 100–300 lg Hypertension, Attention deficit
– hyperactive disorder,
Tourette’s syndrome, growth
hormone deficiency, opioid
withdrawal
Tizanidine Prescription Zanaflex 2–6 mg Skeletal Muscle relaxant
Apraclonidine Prescription Iopidine 0.5% (5 mg/ml) to 1% Glaucoma
(10 mg/ml)
Brimonidine Prescription AlphaganPÒ 0.1% (1 mg/ml) to 0.15% Ophthalmic solution –
(1.5 mg/ml) conjunctivitis (red irritated
eyes)

Initial immunoassay urine screens for common drugs of
abuse were negative in all four children. There was a delay
of several months between initial location of the children
and discovery of the potential offending agent used by
the adult male. This delay precluded any collection of spec-
imens in this case for analysis of tetrahydrozoline. Because
of the lack of confirmation testing, we base our conclusions
on this case based on significant but circumstantial evi-
dence. However the clinical effects presented in these cases
are consistent with the effects caused by tetrahydrozoline,
the active ingredient in VisineÒ.
In future cases suspected of DFSA, clinical effects that
might suggest involvement of an imidazoline would be a
history of deep sedation or coma, bradycardia, miotic
pupils, and hypotension. In cases where presentation of
the alleged victim is delayed, analysis of hair has been
suggested as a viable specimen [9].
In summary we present a series of cases with clinical
effects consistent with the use of tetrahydrozoline, with
duration of sedation consistent with the use of tetrahydroz-
oline and with history and pictorial evidence that suggests
repeated use for DFSA.
 H.A. Spiller et al. / Legal Medicine 9 (2007) 192–195
References
[1] Hurley M, Parker H, Wells DL. The epidemiology of drug facilitated
sexual assault. J Clin Forensic Med 2006;13:181–5.
[2] Kintz P, Villain M, Dumrstre-Toulet V, Ludes B. Drug-facilitat-
ed sexual assault and analytical toxicology: the role of LC-MS/
MS. A case involving zolpidem. J Clin Forensic Med 2005;12:
36–41.
[3] Hindmarch I, Elsohly M, Gambles J, Salamone S. Forensic urinalysis
of drug use in cases of alleged sexual assault. J Clin Forensic Med
2001;8:197–205.
[4] Jackson GF, Dunn WA. An analysis of drug findings in drug-
facilitated sexual assault cases. J Anal Toxicol 2003;27:179.
[5] Scott-Ham M, Burton FC. Toxicological findings in cases of alleged
drug-facilitated sexual assault in the United Kingdom over a 3 year
period. J Clin Forensic Med 2005;12:175–86.
[6] McGregor MJ, Erickson J, Ronald LA, Janssen PA, Van Vliet A,
Schulzer M. Rising incidence of hospital reported Drug Facilitated
sexual assault in a large urban community in Canada. Can J Pub
Health 2004;95:441–5.
[7] Cheza M, Duffort G, Deveaux M, Pepin G. Hair analysis by liquid
chromatography-tandem mass spectrometry in toxicological investi-
gation of drug-facilitated crimes: report of 128 cases over the period
of June 2003–May 2004 in metropolitan Paris. Forensic Sci Int
2005;153:3–10.
[8] Martinez MA, Ballesteros S. An unusual case of drug facilitated
sexual assault using aromatic solvents. J Anal Toxicol 2006;30:
449–53.
[9] Juhascik M, Le NL, Tomlinson K, Moore C, Gaensslen RE,
Negrusz A. Development of an analytical approach to the
specimens collected from victims of sexual assault. J Anal Toxicol
2004;28:400–6.
[10] Gaillard Y, Masson-Seyer MF, Giroud M, Roussot JF, Prevosto JM.
A case of drug facilitated sexual assault leading to death by
chloroform poisoning. Int J Legal Med 2006;120:241–5.
195
[11] Klein-Schwartz W, Gorman R, Oderda GM, Baig A. Central nervous
system depression from ingestion of nonprescription eyedrops. Am J
Emerg Med 1984;2:217–8.
[12] Tobias JD. Central nervous system depression following accidental
ingestion of Visine eye drops. Clin Pediatr 1996;35:539–40.
[13] Jensen P, Edgren B, Hall L, Ring JC. Hemodynamic effects following
ingestion of an imidazoline-containing product. Pediatr Emerg Med
1989;5:110–2.
[14] Daggy A, Kaplan R, Roberge R, Akhtar J. Pediatric Visine
(tetrahydrozoline) ingestion: case report and review of imidazoline
toxicity. Vet Human Toxicol 2003;45:210–2.
[15] Osterhouldt KC, Henretig FM. Sinoatrial node arrest following
tetrahydrozoline ingestion. J Emerg Med 2004;27:313–4.
[16] Lev R, Clark RF. Visine overdose: case report of an adult with
hemodynamic compromise. J Emerg Med 1995;13:649–52.
[17] Schwartz RH, Milteer R, LeBeau MA. Drug facilitated sexual assault
(Date Rape). Southern Med J 2000;93:558–61.
[18] LeBeau MA, Andollo W, Hearn WI, Baselt R, Cone E, Finkle B,
et al. Recommendations for toxicological investigations of drug
facilitated sexual assaults. J Forensic Sci 1999;44:227–30.
[19] Spiller HA, Bosse GM, Anderson LA. Retrospective review of
tizanidine (Zanaflex?) overdose. J Toxicol Clin Toxicol 2004;42:593–6.
[20] Spiller HA, Klein-Schwartz W, Colvin JM, Villalobos D, Johnson
PB, Anderson DL. Toxic clonidine ingestion in children. J Pediatr
2005;146:263–6.
[21] Ali S, Chalut D, Senecal PE. Unintentional ingestion of Brimonidine
ophthalmic drops necessitating intubation. J Toxicol Clin Toxicol
2001;39:501–2.
[22] Quail M, Shannon M. Severe hypothermia caused by clonidine. J
Toxicol Clin Toxicol 2001;39:501.
[23] Mahieu LM, Rooman RP, Goossens E. Imidazoline intoxication in
children. Eur J Pediatr 1993;152:944–6.
[24] Musshoff F, Gerschlauer A, Madea B. Naphazoline intoxication in a
child-a clinical and forensic toxicological case. Forensic Sci Int
2003;134:234–7.