Internal concealment of drugs of abuse (body packing)

INTRODUCTION — "Body packers" are persons who, voluntarily or through coercion, swallow, or insert drug-filled packets into a body cavity, generally in an attempt to smuggle them across secure borders. Body packing was first described in the medical literature in 1973 [1-3]; however, anecdotal reports suggest the practice was utilized by drug traffickers at least a decade prior to recognition. Body stuffing, which involves ingestion of drugs to avoid imminent apprehension by authorities, is a separate but related practice that can lead to acute life-threatening toxicity [4-6].

When body packers present to health care providers, it is typically for one (or more) of the following reasons [7]:

●The patient ("body packer") is asymptomatic but is in the custody of authorities. There is a need for medical evaluation and monitoring.

●The patient has signs of systemic drug toxicity from a ruptured packet.

●The patient has developed symptoms of gastrointestinal obstruction or perforation.

An overview of the internal concealment of drugs of abuse (ie, body packing) is presented here; body stuffing is discussed separately. (See "Acute ingestion of illicit drugs (body stuffing)".)

General aspects of drug intoxication and the diagnosis and management of intoxication with drugs frequently involved in internal concealment are discussed separately. (See "General approach to drug poisoning in adults" and "Cocaine: Acute intoxication" and "Acute opioid intoxication in adults" and "Cannabis (marijuana): Acute intoxication" and "Synthetic cannabinoids: Acute intoxication" and "Acute amphetamine and synthetic cathinone ("bath salt") intoxication" and "Methamphetamine: Acute intoxication".)

People coerced into transporting illicit drugs may be abused in other ways as well. These issues are discussed separately. (See "Human trafficking: Identification and evaluation in the health care setting" and "Evaluation of sexual abuse in children and adolescents" and "Evaluation and management of adult and adolescent sexual assault victims in the emergency department".)

EPIDEMIOLOGY — Body packing is a worldwide phenomenon with case reports published in the United States, Europe, Asia, and Africa [8-12]. It is difficult to estimate the number of body packers who attempt to cross into the United States or other countries. Between 1993 and 2005, 1250 confirmed body packers were apprehended at New York's John F Kennedy International Airport [13]; however, in the months after the terrorist attacks of September 11, 2001, there was a 60 percent increase in the number of body packer arrests, although it is not clear if this is due to increased trafficking, increased surveillance, or a combination of both factors [3].

The internal concealment of drugs of abuse resulted in at least 50 deaths in the greater New York City area between 1990 and 2001, most of which were related to acute toxicity [14]. Initially, body packers were predominantly young males, but subsequently reports document pregnant women and children performing this role [15,16]. Cocaine and heroin are the drugs most often involved in body packing, but methamphetamine, hashish, ecstasy (methylenedioxymethamphetamine), oxycodone, cannabis, and synthetic cannabinoid receptor agonists are also smuggled in this manner [3,8,17,18].

Whereas many patients in early reports suffered drug toxicity from poorly packaged drugs, modern data suggest that leakage is uncommon and that most patients can be managed conservatively [19]. Bowel obstruction occurred in only three percent of patients in the more recent study.

METHODS OF BODY PACKING — The internal concealment of drugs of abuse requires a packing method that allows ingestion or insertion and retrieval of intact packets at some remote time. Primitive wrapping methods, such as duct tape, condoms, or plastics bags tied at one end [2], had a high rate of failure and have largely been replaced by a more sophisticated method involving several layers of latex and an outer wax coating (picture 1 and picture 2) [3,20]. Each of these packets contains approximately 8 to 10 g of drug. Body packers (also pejoratively called "mules" or "swallowers") generally ingest between 50 to 100 drug containers prior to departure, but larger numbers are reported [10]. Occasionally, smaller numbers of packets are inserted rectally or vaginally. In addition, attempts to avoid detection can involve alteration of the form of the drug. As an example, liquid cocaine has been used in body packets, making them more difficult to identify on radiography [21,22].

After ingestion, antimotility drugs (eg, loperamide or diphenoxylate-atropine) are often used to slow intestinal motility. Once they arrive at their destination, body packers often use promotility drugs (eg, magnesium hydroxide or magnesium citrate) to promote packet expulsion and retrieval.

DIAGNOSIS

Overview — In many cases, body packers are identified by law enforcement officials and referred to clinicians for evaluation, management, and packet recovery. However, a substantial number of patients present to physicians with symptoms either related to intestinal obstruction or drug toxicity. Both complications are potentially fatal if the underlying diagnosis is not recognized clinically.

The diagnosis of body packing is established based upon a suggestive history, findings on the physical examination, and diagnostic imaging, usually a plain radiograph of the abdomen. An approach to diagnosis and further management of these patients is outlined in the attached table (table 1). The clinical manifestations of opioid (eg, heroin) and cocaine toxicity are described in detail separately. (See "Acute opioid intoxication in adults", section on 'Clinical features of overdose' and "Cocaine: Acute intoxication", section on 'Clinical manifestations'.)

Because trafficking of other drugs (cannabis, synthetic cannabinoid receptor agonists) is uncommon, patients should be managed on an individual basis. For general guidance, it is reasonable to manage patients who have ingested drugs with known life-threating toxicity similar to cocaine patients and others similar to opioid patients.

History and physical examination — Although body packers often provide unreliable information to avoid prosecution, every attempt should be made to elicit an accurate history that includes the following:

●Drug being carried

●Type of packet wrapping (home-made or improvised wrapping is more likely to leak or rupture)

●Number of packets ingested

●Presence of gastrointestinal effects (eg, pain, distention, or obstipation) suggesting obstruction or perforation

●Personal use of drugs of abuse (for interpretation of toxicology testing)

●Use of promotility or antimotility pharmaceuticals

It is generally believed that most body packers know exactly the number and contents of their packages because they are required to deliver a given number upon arrival. Multiple motives could cause them to over-report the package number (to stay in the hospital) or under-report the number (to deliver a drug packet in the prison system).

A thorough physical examination should be performed, with a focus on the following issues:

Physical evidence of body packing — Packets may be felt on abdominal, vaginal, or rectal examination, and provide clear evidence of body packing prior to diagnostic imaging. Such information is of particular importance when the patient is clinically unstable at presentation.

Drug toxicity — The presence of a "toxic syndrome" or "toxidrome" (a constellation of physical findings suggesting toxicity from a particular drug) suggests leakage of drug from a drug packet. The attached table summarizes the findings associated with common toxic syndromes (table 2). The opioid toxic syndrome (such as occurs with heroin) consists of a depressed mental status, decreased respirations, miotic pupils, and decreased bowel sounds. (See 'Opioid toxicity' below and "Acute opioid intoxication in adults".)

The sympathomimetic toxic syndrome (resulting from cocaine or amphetamine/amphetamine analogues) consists of agitation, hypertension, tachycardia, mydriatic pupils, and diaphoresis. Cocaine or amphetamine toxicity in a patient with a large intestinal burden of drug is life-threatening and requires immediate intervention. Patients with more severe toxicity from a ruptured cocaine or amphetamine packet present with seizures, hyperthermia myocardial ischemia, heart failure, ventricular dysrhythmias, or coma. (See 'Sympathomimetic (cocaine or amphetamine) toxicity' below and "Cocaine: Acute intoxication" and "Acute amphetamine and synthetic cathinone ("bath salt") intoxication" and "Methamphetamine: Acute intoxication" and "Cannabis (marijuana): Acute intoxication" and "Synthetic cannabinoids: Acute intoxication".)

Intestinal obstruction or perforation — Bowel obstruction [2,23,24] and perforation [25,26] occur more commonly than gastric [27,28] or esophageal obstruction [29,30] or perforation [29], but all are reported. Abdominal distention, tenderness, and abnormal bowel sounds (which may be high-pitched, tinkling, or absent) all suggest bowel obstruction; peritoneal signs suggest bowel perforation. (See "Evaluation of the adult with nontraumatic abdominal or flank pain in the emergency department" and "Etiologies, clinical manifestations, and diagnosis of mechanical small bowel obstruction in adults".)

Diagnostic imaging

Indications and approach to radiographic evaluation — Radiography should be performed in patients suspected of body packing and begins with a screening examination, generally a plain abdominal radiograph or ultrasound. More advanced imaging studies (abdominal computed tomography [CT] or barium enhanced radiography) are indicated when a screening examination is negative in a patient in whom there is high suspicion of internal concealment. Abdominal CT or barium enhanced radiography are used more commonly following a known ingestion to guide surgical intervention and document clearance of all packets. CT, which can be performed without water-soluble contrast, is preferable if perforation is suspected. Liquid cocaine (and presumably the liquid form of other drugs) is more difficult to detect radiographically given its aqueous base and therefore radiographic appearance similar to tissues [22]. (See 'Treatment' below.)

Plain abdominal radiograph — Radiographic evaluation of the body packer generally begins with plain abdominal radiography. There are several signs on the plain abdominal radiograph that suggest body packing:

●Repeating geometric patterns (image 1 and image 2 and image 3)

●A rim of air trapped between two condoms, making the drug packets stand out in relief (the "double condom sign") (image 4) [31]

●Air in the tied ends of condoms (the "rosette sign") [24,32]

Pooled data suggests that the sensitivity of a single abdominal radiograph is 85 to 90 percent [3]. However, the true sensitivity is difficult to assess and may be lower, as a substantial number of drug packets are not visualized on plain films [2,23,33-35]. As an example, in a retrospective study radiologists provided with clinical information about each case could not reach agreement on the presence or absence of packets on a plain abdominal radiograph in 14 percent (41/279) of studies [34]. False positive studies can also occur in the setting of bladder stones, hardened stool (image 5A-B), or intraabdominal calcifications (image 6) [36].

Ultrasound — Only a few studies describe the use of ultrasound to screen potential body packers, but these reports suggest that this technology has a diagnostic accuracy similar to plain radiography. In two small, blinded studies, ultrasound correctly identified the subjects with a positive abdominal radiograph [37,38]. Another blinded study of 50 body packers compared ultrasound to traditional methods of screening (abdominal radiography or monitored stools) [39]. Ultrasound had a diagnostic accuracy of 94 percent and required only 5 to 10 minutes to perform. However, because of the high pretest probability among these subjects, all of whom had been retained by officials due to suspicion of body packing, the true accuracy of ultrasound remains undefined. False negative results have been reported when packets were in the rectum [40]. Thus, while a positive ultrasound is likely sufficient to confirm a suspicion of body packing, a negative study should never be used to exclude the diagnosis, especially when a small number of packets are suspected. For patients with contraindications to radiation (eg, pregnant women), magnetic resonance imaging (MRI) can be performed as a second study.

Advanced abdominal imaging — Advanced radiographic imaging (barium-enhanced abdominal radiography or contrast-enhanced abdominal computerized tomography [CT]) is indicated in one of two circumstances. Infrequently, it is used to diagnose body packing in whom the initial screening study (plain radiography) is negative, but in whom the index of suspicion is high. More often, these studies are used to exclude obstruction or confirm clearance of the gastrointestinal tract after treatment. (See 'Indications and approach to radiographic evaluation' above.)

CT and barium-enhanced radiography are both more sensitive than plain abdominal radiographs for detecting drug packets [33,41,42]. In addition, 3-dimensional CT scans, which are increasingly available, provide detailed views of the abdominal contents [43]. Packets on CT may appear as foreign bodies surrounded by a rim of gas (image 7 and image 8). Packets on barium radiography generally appear as filling defects.

While most case reports and series confirm the utility of CT as a screening tool, at least two reports demonstrate that CT is limited for determining the exact number of packets ingested and single packets may remain after decontamination or a period of observation [44,45]. With advanced CT scanning, the contents of packets can be identified by their density as measured in Hounsfield units (HU; cocaine: -219 HU; heroin: -520 HU; cannabis: 700 HU) [46].

The results of one preliminary study suggest that the abdominal CT scout views have a high sensitivity for detecting drug packets, use a lower dose of radiation than plain films, and can be followed with a full CT if enhanced imaging is necessary [47]. While CT scanning offers some logistical disadvantages, this study offers a potential new perspective on screening.

MRI provides a radiation-free assessment of the abdomen. Although its diagnostic performance as a screening tool is undefined [21], preliminary studies are encouraging with 100 percent sensitivity and 75 percent specificity reported in a study of 16 patients [21]. Concerns exist regarding the limited availability of MRI machines and the time required to perform a study.

Urine drug testing — The role of urine toxicology testing in the detection of body packers is controversial. Sensitivities in larger studies have ranged from >90 percent to <40 percent [48]. The disparate sensitivities of published trials lead us to believe that urine toxicology testing should not be used as a screening test for potential body packers [3].

Law enforcement field testing of the actual packet content, which provides an accurate drug profile in minutes, is the ideal test to determine packet content. In the event that such testing is unavailable, urinary toxicology testing may be an acceptable surrogate. In several reports, findings on urine toxicology tests correlated well with the subsequently identified packet contents.

However, negative urine toxicology tests in documented body packers are common. Furthermore, such testing may be misleading. As an example, in one case report the urine specimen from a cocaine body packer tested negative for cocaine but positive for opiates [49]. However, once body packing is confirmed, an initial negative urine screen that subsequently turns positive is highly suggestive of packet leakage.

TREATMENT — Once gastrointestinal drug smuggling is identified, specific treatment depends upon the drug involved, as well as the presenting symptoms and signs. Determining when to perform a study to confirm gastrointestinal clearance following decontamination is difficult. As a first step, the packet count can be used. In most patients, a confirmatory study should be performed after the passage of at least two or three packet-free stools. An algorithm summarizing the management of body packers is provided (algorithm 1).

Asymptomatic patients — Patients who are asymptomatic should be managed expectantly, without surgery, with close monitoring in an intensive care setting until the passage of all packets is complete. This approach is supported by a number of large case series [10,19,50,51].

We suggest that treatment with whole bowel irrigation (WBI) be started with a polyethylene glycol/electrolyte lavage solution (PEG-ELS) such as GoLytely, at a rate of 2 L per hour in adults. In practice, it is difficult for a patient to consume PEG-ELS voluntarily at a rate of 2 L per hour, and a nasogastric tube is typically required to ensure an adequate rate of administration.

Although there are no controlled studies, WBI has been used safely for years in patients with gastrointestinal drug smuggling [52,53], and probably helps speed passage of packets. We suggest that promotility drugs be given to patients being treated with PEG-ELS, as these drugs improve the tolerability of WBI and hasten drug removal [54]. Although published evidence is scant, based on our clinical experience, either metoclopramide (10 mg intravenously [IV]) and/or erythromycin (500 mg IV) can be used to increase motility. There is no role for cathartics as they can lead to fluid and electrolyte abnormalities. Caution is advised to check and monitor the QT interval when these drugs are used, especially in cases of cocaine body packing or if loperamide was used prior to presentation. If the QT interval is prolonged, we forgo the use of promotility drugs and use WBI alone.

There are no controlled studies of activated charcoal (AC) in body packers and in general we do not suggest treatment with AC in this setting. AC is likely to be more useful in body stuffers (those who ingest drugs to avoid imminent apprehension by authorities). In body packers, AC might improve outcomes in the event of a ruptured cocaine packet, but the large doses needed would be impractical and AC could be detrimental in the case of bowel perforation or if surgery or endoscopy were required.

Opioid toxicity — Body packers who present with opioid toxicity from heroin or another opioid should be treated with naloxone (Narcan). Naloxone is a competitive antagonist at the opioid receptor that reverses the depression in mental status, hypoventilation, pinpoint pupils, and decreased bowel motility of opioid overdose. However, it does not reverse opioid-induced acute respiratory distress syndrome (ARDS). Patients with opioid-induced ARDS are managed in accordance with current standards. (See "Acute opioid intoxication in adults", section on 'Clinical features of overdose' and "Acute opioid intoxication in adults", section on 'Lung injury and ARDS'.)

Enormous amounts of heroin are released when a single packet ruptures; consequently, very high doses of naloxone may be required to reverse toxicity in body packers. In such patients with severe respiratory depression, an appropriate initial dose is 2 to 5 mg IV, with repeat doses of 2 mg given every five minutes until the patient is responsive. The total amount given to achieve a response should then be given every hour as a continuous naloxone infusion until all packets have passed.

Once the patient with heroin toxicity is stabilized with naloxone, they should be managed in a similar fashion to the asymptomatic body packer.

Sympathomimetic (cocaine or amphetamine) toxicity — Body packers who present with cocaine toxicity should receive immediate, emergency surgical evaluation and be taken to the operating room for surgical decontamination. There is no "antidote" for cocaine or amphetamine toxicity, and therefore no place for conservative management of these patients [55]. (See "Cocaine: Acute intoxication" and "Clinical manifestations, diagnosis, and management of the cardiovascular complications of cocaine abuse" and "Pulmonary complications of cocaine use" and "Acute amphetamine and synthetic cathinone ("bath salt") intoxication".)

Pharmacologic stabilization of symptomatic patients with sympathomimetic toxicity is appropriate, but not definitive, and should not delay transfer to the operating room. Symptoms of profound toxicity and their treatment include the following:

●Hyperthermia – Active external cooling (ice water immersion) and intravenous (IV) benzodiazepine therapy (midazolam 1 to 2 mg IV, or diazepam 5 to 10 mg IV, with rapid escalation in dosing as necessary).

●Hypertension – IV benzodiazepine therapy (midazolam 1 to 2 mg IV, or diazepam 5 to 10 mg IV), repeated as necessary); phentolamine, 1 to 5 mg IV; nitroprusside, 0.3 to 3 mcg/kg/min; nitroglycerin, 0.25 to 0.5 mcg/kg/min, or nicardipine 5 mg/hour IV increased by 2.5 mg/hour every 5 to 15 minutes to a maximum of 15 mg/hour.

●Seizures – IV benzodiazepine therapy (lorazepam 2 to 4 mg IV or midazolam 1 to 2 mg IV, repeat as necessary), followed by propofol 5 to 100 mcg/kg per minute, if needed.

●Ventricular dysrhythmias – IV benzodiazepine therapy (midazolam 1 to 2 mg IV, or diazepam 5 to 10 mg IV, followed rapidly by hypertonic sodium bicarbonate if the QRS complex is greater than 120 msec). For unstable rhythms that are not responsive to these therapies, standard doses of amiodarone should be administered.

Obstruction or perforation — Gastrointestinal obstruction or perforation occurs infrequently, but has become increasingly important compared to leakage given the improvement in packet construction. Intestinal complications are more common than esophageal complications, but both are reported.

The treatment of these patients is surgical. The patient with evidence of gastrointestinal perforation should undergo immediate exploratory laparotomy. One or more enterotomies should be made in the bowel; packets are then "milked" towards the enterotomy site or the anus [56,57].

After surgical decontamination, the patient should undergo an advanced radiographic imaging study to document a clear GI tract, as packets may be missed during operative evaluation [58].

Endoscopic removal of packets — Although endoscopic removal is highly controversial, there are reports of successful endoscopic removal of drug packets [59-62]. The risk associated with this approach is primarily packet perforation, which can release dangerous amounts of drug.

With the sophisticated packaging now commonly used by body packers, we believe that endoscopy is safe when performed in a highly controlled setting, especially when a packet that has already passed is available to test its strength against the snare. Only asymptomatic patients are candidates for endoscopy and only when whole bowel irrigation has failed or is otherwise contraindicated. Since each packet requires repeated passage of the endoscope, endoscopy is generally only considered for removal of a remaining packet or a few packets that have failed to pass the pylorus. Surgical backup should be available in case packet rupture occurs.

Documentation of packet clearance — Due to the risk of delayed leak from a retained packet, complete gastrointestinal decontamination should be documented prior to discharge. Relying on a packet count based on the history is inadequate. Passage of two or three packet-free bowel movements has not proven to be sufficient [63]. Plain abdominal radiographs are not sufficiently sensitive to detect a single or small number of packets. Therefore, most authorities recommend using contrast-enhanced plain radiography or, increasingly, contrast-enhanced CT scan [36]. Lower-radiation CT and MRI may be suitable alternatives, but are not preferred because they are less well studied [64,65].

Disposition — All patients identified with internal drug smuggling should be admitted to an intensive care setting, regardless of symptoms. Patients are stable for discharge once all signs of toxicity have resolved, there is no radiologic evidence of internal packets, and they have passed three packet-free stools.

ADDITIONAL RESOURCES

Regional poison control centers — Regional poison control centers in the United States are available at all times for consultation on patients with known or suspected poisoning, and who may be critically ill, require admission, or have clinical pictures that are unclear (1-800-222-1222). In addition, some hospitals have medical toxicologists available for bedside consultation. Whenever available, these are invaluable resources to help in the diagnosis and management of ingestions or overdoses. Contact information for poison centers around the world is provided separately. (See "Society guideline links: Regional poison control centers".)

Society guideline links — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General measures for acute poisoning treatment".)

SUMMARY AND RECOMMENDATIONS

●Packet concealment and contents – Body packers are individuals who attempt to smuggle drugs, most frequently cocaine or heroin, by internal concealment. Most often, drug packets are swallowed, but they may be inserted into the rectum or vagina. Each packet contains approximately 8 to 10 g of drug. Packers generally swallow between 50 to 100 drug containers, but larger numbers may be involved. (See 'Methods of body packing' above.)

●History – Although body packers may be unreliable, every attempt should be made to elicit an accurate history that includes the following: drug being carried; type of packet wrapping; number of packets ingested; and the presence of gastrointestinal symptoms (pain, distention, or obstipation) suggesting obstruction or perforation. (See 'History and physical examination' above.)

●Clinical presentation and examination – Body packers typically present in custody and without symptoms, with signs of systemic drug toxicity if a packet ruptures, or with symptoms and signs from intestinal obstruction or perforation. Packets are sometimes felt on abdominal, vaginal, or rectal examination. The presence of a "toxic syndrome" or "toxidrome" (a constellation of physical findings suggesting toxicity from a particular drug) suggests leakage of drug from a drug packet. Of particular importance are symptoms and signs consistent with cocaine toxicity (agitation, hypertension, tachycardia, mydriatic pupils, and diaphoresis), which should be presumed to be fatal given the large doses found in packets. The attached table summarizes the findings associated with common toxic syndromes (table 2).

●Diagnosis – Diagnosis of body packing is usually confirmed through radiographic imaging, usually a plain abdominal radiograph. Urine toxicology testing is an unreliable method for screening potential body packers and should not be used for this purpose. (See 'Indications and approach to radiographic evaluation' above.)

●Management of asymptomatic patients – Patients who are asymptomatic can be managed expectantly, without surgery, with close monitoring in an intensive care setting until the passage of all packets is complete. We suggest treating asymptomatic patients with whole bowel irrigation using a polyethylene glycol/electrolyte lavage solution to promote clearance (Grade 2C). An algorithm summarizing the management of body packers is provided (algorithm 1). (See 'Asymptomatic patients' above.)

●Management of heroin toxicity – Patients who present with heroin toxicity should be treated with naloxone. Enormous amounts of heroin are released when a single packet ruptures; consequently, very high doses of naloxone may be required to reverse toxicity. An appropriate initial dose is 2 to 5 mg IV, with repeat doses of 2 mg given every five minutes until the patient is responsive. (See 'Opioid toxicity' above.)

●Management of sympathomimetic toxicity – Patients who present with sympathomimetic (cocaine or amphetamine) toxicity should receive immediate, emergency surgical evaluation and be taken to the operating room for surgical decontamination. (See 'Sympathomimetic (cocaine or amphetamine) toxicity' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Lewis Nelson, MD, who contributed to an earlier version of this topic review.

The UpToDate editorial staff also acknowledges Stephen J Traub, MD, former section editor of the toxicology program, for 20 years of dedicated service.