Packers and Stuffers: Contraband in the ED

Trivia question #1:  What is the latest mode of transportation for the illegal smuggling of large amounts of cocaine? 
Answer:  Privately-owned submarines. Five tons of cocaine worth over 350 million dollars was discovered in a submarine off the Guatemala coast in 2008.

After evaluating this article participants will be able to:
-Identify issues associated with body packers and stuffers
-Implement different treatment strategies for body packers and stuffers
-Recognize the critical differences between body packers and stuffers

 

The patient is a 30-year-old male who presents to an inner city ED after “swallowing several dime bags of cocaine” approximately 1 hour ago while being pursued by the police. He complains of chest pain and headache but is refusing any medical intervention and wants to sign out AMA. He is agitated, diaphoretic, and verbally abusive to the ED staff. His vital signs document a pulse of 120 beats per minute; respiratory rate of 32 breaths per minute; blood pressure of 180/110mmHg and an oral temperature of 102 F.

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With international drug trafficking on the rise, it is important for emergency physicians to be aware of methods of drug concealment. “Body stuffers” is the term used to describe individuals who rapidly swallow illegal contraband such as cocaine or heroin in an attempt to avoid prosecution when confronted by the police or authorities. “Body packers” swallow or pack a selected body orifice with drugs in an attempt to conceal and illegally transport paraphernalia across international borders. Body packing uses more methodical means of packaging such as multilayered latex, rubber or condoms to prevent the packets from rupturing in transit (figure 1).

 

 

 

The average number of packets ingested may vary, but can be well over 100. Massive overdose will occur in individuals if any of these packets rupture, releasing a potentially lethal dose of drug. Body packers often ingest constipating agents such as diphenoxylate/atropine (Lomotil) to hold back the intestinal contents during long flights or transport. In contrast, body stuffers generally have poorly wrapped drugs, which are likely to be systemically absorbed, although in much less concentrated amounts than the body packer scenario. Packaging methods likely to leak include paper, aluminum foil, duct tape (yet another use), and loosely secured plastic bags.

The physician should attempt to obtain any information regarding the amount of drug ingested and the type of packaging to predict the potential for toxicity. Plain abdominal radiographs are generally not useful for body stuffers, but may be positive with body packers (figure 3). Gastrograffin swallow or CT scan of the abdomen with contrast may reveal ingested packets in cases where plain radiographs are negative, but tend to be nonspecific and reader dependant. ED bedside ultrasonography would be a noninvasive method to rapidly assess for multiple drug packets, particularly in the gastric region.

 

 

 

In overdose, cocaine toxicity will cause a sympathomimetic toxidrome manifested by agitation, mydriasis, diaphoresis, hypertension, tachycardia, and hyperthermia.

 

Benzodiazepines are the first line agents for reversing mild to moderate cocaine-induced sympathetic symptoms. Active cooling measures are critical in victims with profound hyperthermia. Cardiotoxicity manifesting as acute coronary syndromes and myocardial infarctions, as well as cerebral vascular accidents and intracranial bleeds have been well documented in patients with cocaine toxicity. 

In body stuffers and packers, gastric lavage is ineffective and contraindicated, as the procedure may cause rupture of the packets. Conservative therapy using polyethylene glycol whole bowel irrigation (WBI) is generally recommended in patients with potential toxicity. The most common product, trade named “GoLytely”, (I challenge anyone to come up with a better medical misnomer) is dosed at 1-2 liters per hour. It often requires NG tube administration unless the patient is cooperative. In patients who are extremely agitated, combative or exhibit violent behavior, WBI should be withheld. Activated charcoal is given prior to whole bowel irrigation to adsorb any leaking drug from the packets. Charcoal noted in the rectal effluent also helps indicate a completed round of WBI. It is important to ensure that all ingested packets are accounted for before the patient is discharged. After cleaning off the charcoal residue, turn any illegal contraband over to hospital security or the proper authorities—for obvious reasons, avoid “pocketing the evidence”. Patients in police custody are particularly high risk for subsequent morbidity due to a lack of reliable follow-up care or means of close observation and monitoring. Body packers with significant toxicity or evidence of bowel obstruction should have a surgical consultation. Laparotomy may be a necessary lifesaving intervention to remove leaking packets.

Body packers or stuffers with heroin or opioid-containing drugs may present with altered mental status, depressed respiratory drive, and miotic pupils. These patients may also require GI decontamination with whole bowel irrigation in order to enhance the elimination of drug packets. Contraindications to WBI include unstable vital signs, respiratory compromise, and lack of bowel sounds or gut motility. In contrast to scenarios involving cocaine, a less aggressive approach to surgical intervention is warranted with heroin packing. Supportive care and antidotal therapy with naloxone may be required for more prolonged periods of time. A recent five year case series from Chicago reported a relatively benign clinical course in most heroin body stuffers. Nine percent of patients developed signs and symptoms consistent with opiate intoxication and only 5% required naloxone administration. The mean observation time in this series was 24 hours.

Other drugs of abuse described in isolated cases of body packers and stuffers include methamphetamines, phencyclidine, cannabinoids and various hallucinogens.

Answer: They were being used as “body packers” to smuggle cocaine into the US from South America.

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