Packers, pushers and stuffers--managing patients with concealed drugs in UK emergency departments: a clinical and medicolegal review

Abstract

Body packing, pushing and stuffing are methods by which illicit drugs may be carried within the human body. Patients involved in these practices may present UK emergency departments with complex medical, legal and ethical considerations. This review article examines not only the evidence behind the clinical management of these patients, but also the legal powers afforded to the authorities to authorise the use of intimate searches and diagnostic imaging for forensic purposes. Serious complications from concealed drug packets are now rare, and most asymptomatic patients may be safely discharged from hospital after assessment. Emergency surgery is indicated for body packers with cocaine poisoning and for some cases of heroin poisoning. Urgent surgery is indicated for obstruction, perforation, the passage of packet fragments and failure of conservative treatment. Guidance is given for doctors who are faced with requests from the authorities to perform intimate searches and diagnostic imaging for forensic purposes.Concealment of illicit drugs may occur in a number of settings. Body packers swallow drugs in rubber or latex packets in an attempt to transport them across international borders without detection. 1Body pushers insert drug packets into the rectum or vagina. The number and size of the packets may vary, but each one will usually contain many times the toxic dose of the drug, most commonly either cocaine or heroin. The sophistication of the packaging methods used by drug smuggling organisations results in a low morbidity to their ''drug mules'', although packet failure may still cause poisoning in the country of origin, 2 during flight, 3 or at their destination. 4 Body stuffers spontaneously swallow either unwrapped or poorly wrapped drugs when fearing apprehension by the authorities, in order to dispose of evidence and frustrate the legal process.5 They are distinct from pushers and packers in the amount of drug and integrity of packaging used.The Drugs Act 2005 gives additional powers to the police services of England and Wales to authorise imaging of suspected body packers. The aim of this article is to provide an evidence-based approach for the emergency department (ED) management of suspected body packers, pushers and stuffers, and to summarise the law relating to forensic imaging. METHODSA comprehensive literature search was carried out using the Datastar interface. Search terms included ''body packing'', ''foreign bodies'', ''stomach'', ''heroin'', ''cocaine'' and ''drug''. The databases interrogated were Medline (1950 to December 2006), CINAHL (1982 to January 2007 and EMBASE (1974( to January 2007. Papers were included if they contained original data regarding body packing. The bibliographies of relevant papers were examined and cross-referenced. Papers were critically appraised for the quality of evidence presented. The criteria used were relevance to the question asked and study design. Studies were preferred in accordance with the usual hierarchy of evidence, namely controlled clinical...

Body Pushers: Low-Dose CT, Always the Best Choice? A Study of the Diagnostic Performance of CT Scout View

“…No significant change for NPV could be observed, as a negative read with high confidence was only given 4 times in total. The sensitivity of a typical X-ray in diagnosing BP has been reported to ranging from 47% -95% [21] [23], the sensitivity of CT has been reported to be close to 100% [3] [24]. The sensitivity of CT scout view in our human collective of mostly body stuffers was 73% with an especially high PPV, consistent with the higher sensitivity of CT scout view when compared to X-ray as reported in an animal model [12] or for body packing with packets in the upper and mid GI [17].…”

Mystifying Toxidrome: A Case of Heroin Body Packer Syndrome

“…Body packers, also known as swallowers, internal carriers, couriers or mules, ingest wrapped packets (pellets) containing illicit drugs for purpose of smuggling across borders, while body pushers, with same purpose insert into rectum/vagina. A body stuffer, also known as mini-packer, conversely without smuggling intention ingests poorly wrapped drugs to conceal its presence from custom authorities to avoid arrest or detention (Booker et al, 2009). Body packers/pushers usually smuggle cocaine, less commonly heroin and rarely amphetamine, ecstasy (3,4 -MDMP), marijuana and hashish (Traub et al, 2003).…”

“…Since then, a few case reports and retrospective observational studies are reported but smuggling of drugs has evolved both in methods of trafficking with better concealment (e.g., using automatic crafted packing system leading to minimal chance of rupture/leak or use of aluminum foil, plastic food wrap, carbon paper to alter radio density limiting detection by authorities) and methods of detection by increasing security in airport, marine or border area (Pidoto et al, 2002). Packet failure may occur in country of origin, during flight or at their destination and may present to health care providers as Body packer syndrome (Booker et al, 2009) . Drug trafficking is a global illicit trade, continuously monitored by United Nations Office on Drugs and Crime (www.unodc.org) and many countries are signatory to international Conventions (e.g., Single Convention on Narcotic Drugs, 1961, Convention on Psychotropic Substances, 1971 and the UN Convention Against Illicit Traffic in Narcotic Drugs and Psychotropic Substances, 1988, http://cbn.nic.in); however, each country's legal policy controls it independently.…”

Walking on thin ice! Identifying methamphetamine “drug mules” on digital plain radiography

“…Body stuffers, including traffickers and users, ingest intentionally small amounts of loosely wrapped drug pellets (typically initially hidden in the mouth), usually immediately before an unexpected encounter with law enforcement. [5][6][7][8][9][10] The generally accepted radiological examination is a plain abdominal radiograph in the supine projection. [4][5][6] This technique is widely available at a low cost and is a simple method of detecting drug-filled packets within the alimentary tract.…”