Tramadol in drug-facilitated sexual assault: global case prevalence, pharmacology, and drug interactions

Drug-facilitated sexual assault (DFSA) refers to sexual acts where the victim is incapacitated by the effects of psychotropic substances, causing impaired ability to prevent an attack and/or provide informed consent. To date, the level of understanding of the prevalence of the specific drugs involved in DFSA has been limited. This review examines global toxicological case data to assess the prevalence of tramadol, a widely prescribed opioid analgesic, in the context of DFSA. Tramadol was confirmed in reports across Africa, Oceania, Europe, the Middle East, and North America, with detection rates ranging from 1% to 33%. In these cases, 17 voluntary and involuntary drug combinations were identified including alcohol, opioids, benzodiazepines, Z-drugs, cannabinoids, and stimulants. These substances pose significant risk for both pharmacodynamic and pharmacokinetic interaction with tramadol, potentially altering plasma metabolite levels, clearance times and also central nervous system depression, facilitating DFSA and influencing forensic detection and interpretation of tramadol and its metabolites. Overall, this review underscores the significance of tramadol in DFSA casework and highlights the importance of drug-drug interactions in order to improve forensic analysis in DFSA casework and aid in legal action leading to victim support and closure.