Body packing and body stuffing involve swallowing drug-filled packets or placing them in body cavities (eg, rectum, vagina) to evade detection by law enforcement. Rupture of packets may result in drug absorption with potential overdose; overall medical risks vary depending on the amount and type of drug and the way it is packaged.
Body packing is the deliberate ingestion well-sealed packets that contain large amounts of high street value xenobiotics (eg heroin, cocaine). Body packing is done to smuggle the illicit xenobiotics across security checkpoints, such as at international borders. The drugs may be placed in condoms or in packets enclosed by several layers of polyethylene or latex and sometimes covered with an outer layer of wax. After a person swallows multiple packets, often they take antimotility drugs (eg, loperamide, diphenoxylate-atropine), essentially intentionally inducing an ileus, to avoid passing the drugs with a bowel movement until the packets can be retrieved. When the person arrives at their destination, a cathartic is often given to stimulate gastrointestinal passage of the product.
Body packing has been most extensively described with cocaine. Each packet can contain nearly 10 g of cocaine. Individuals may swallow as many as 150 packets. For context, insufflation of about 1 g of cocaine is likely fatal. People who have swallowed the packets is likely to know how many packets they ingested but may be reluctant to share that information.
Body packing is associated with a higher risk of mortality than body stuffing and with people who are being exploited or coerced by others individuals. They may be victims of human trafficking, including sex trafficking. If trafficking is suspected, the appropriate authorities should be notified.
Body stuffing refers to the abrupt ingestion or placing into body cavities (eg, mouth, rectum, vagina) of poorly packaged or unpackaged drugs to avoid detection when arrest by law enforcement is imminent. In contrast to packing, stuffing is usually an unplanned event that involves a spontaneous insertion of small amounts of poorly packaged material into a body cavity, usually into the mouth. The substances are often encased in poorly sealed vials or packets that may not be evident on radiographs. In general, patients ingest nonlethal doses.
Symptoms and Signs of Body Packing and Stuffing
Symptoms correspond to the substance that has been ingested.
Body stuffing is more likely to be symptomatic than body packing because of inadequate or absent packaging, but less likely to require intervention because of the smaller amount ingested. Patients with suspected body packing or stuffing may be brought to medical attention by law enforcement officials.
A person involved in body packing may present without symptoms or for unrelated reasons. The patient may not be forthcoming, owing to the presence of law enforcement or fear of retribution by people coercing or threatening the individual. Clinicians should consider body packing in recent travelers and newly incarcerated people who present with coma, seizures, or abdominal pain of unknown etiology.
The development of symptoms is presumed to be due to packet rupture until proven otherwise. The ruptured packet will have local effects first, such as intestinal ischemia manifesting as intense paroxysmal abdominal pain with hyperlactatemia.
Diagnosis of Body Packing and Stuffing
History
Pelvic and/or digital rectal examination (if the patient is able to provide consent)
Computed tomography (CT) without contrast
A medical history is elicited but, as noted, patients will often not admit to body packing or body stuffing.
If the patient is conscious, consent should be attained to perform a pelvic examination and/or digital rectal examination to evaluate for the presence of drug packets. The clinician should be careful not to rupture packets during the examination.
When CT is performed, counter intuitively, use of oral contrast may decrease the sensitivity because oral contrast and cocaine have similar densities (1). Pure cocaine has a density of 200 Hounsfield Units (HU) and heroin about 500 HU. CT imaging can also assess the gastrointestinal track and also other body cavities, such as the vagina, that may be problematic to initially evaluate by other methods.
Radiographs are not sensitive or specific enough to detect the presence of packets in the gastrointestinal tract. MRI is of limited value in detecting drug packets because of the lack of protons and motion artefacts caused by the bowel loops. The optimal MRI evaluation would be preceded by inhibition of peristalsis, which would delay treatment and increase the risk of an obstruction.
Diagnosis reference
1. Pinto A, Reginelli A, Pinto F, et al. Radiological and practical aspects of body packing. Br J Radiol. 2014;87(1036):20130500. doi:10.1259/bjr.20130500
Treatment of Body Packing and Stuffing
Body stuffing: Usually observation
Body packing: Observation while waiting for passage of drug packets
Sometimes measures to remove drug packets
Sometimes antidotes to specific drugs
Management of complications
Body stuffing is usually asymptomatic and patients with known or suspected body stuffing may be discharged once their vital signs are consistently in a normal range and if the rest of the evaluation raises no other concerns.
For body packing, once the diagnosis is made, the clinician should:
Determine which drug and the amount of drug the patient is transporting
Ensure passage of all drugs
Prepare to intervene immediately if there are signs of rupture
Additional treatment depends on the substance being transported. Body packing may result in a need for emergent surgery (for ruptured cocaine packets) or intubation (for opioid packets) (1). Rupture of a single cocaine packet can be fatal. Each packet contains almost 10 times the lethal dose.
Vaginal and rectal packets should be removed during physical examination, if the patient consents to the examination and removal is feasible without rupturing packets. If a situation arises in which law enforcement requests these examinations despite the patient refusing and having capacity to refuse, hospital legal counsel and administration should be notified and proper procedures should be followed based on local policies, regulations, and laws. Clinicians in an office-based practice should refer these patients to the hospital because there is a risk of life-threatening complications.
Whole-bowel irrigation (WBI) with polyethylene glycol may speed elimination. Activated charcoal given at the start of WBI may help to identify when the otherwise clear solution of polyethylene glycol has reached the rectum. Whole bowel irrigation is contraindicated in patients with signs of obstruction, surgical alteration of the gastrointestinal tract (eg, gastric bypass), or signs of perforation. Ideally whole bowel irrigation is performed after CT scan. Activated charcoal should not be given in any symptomatic patient because charcoal can obscure the endoscopic and surgical fields of view. Instead, the procedure should be expedited. If rupture of the packets is suspected, immediate removal is indicated by endoscopy or laparoscopy. Unfortunately, death commonly occurs because a large quantity of drug is released.
Oral methylnaltrexone may be considered in patients who report that they ingested opioids or loperamide to prolong bowel transit time, although no studies have evaluated this practice.
Several measures are not recommended. Oil-based laxatives or enemas should not be used because they may dissolve the casing of the drug packets. Oral promotility agents such as metoclopramide have no demonstrated effect. Upper endoscopy is not indicated for asymptomatic patients unless the CT scan shows the majority or totality of drug packets are in the stomach. Endoscopic removal is risky because the packets may rupture during retrieval.
The clinician should consider the vulnerable position of body packing patients who may not have had regular medical care previously and fear retribution for themselves or their loved ones. Clinicians may involve the hospital administration who can consider involving legal counsel and law enforcement. The clinician should evaluate whether the patient requires psychosocial support.
Treatment reference
1. Alfa-Wali M, Atinga A, Tanham M, Iqbal Q, Meng AY, Mohsen Y. Assessment of the management outcomes of body packers. ANZ J Surg. 2016;86(10):821-825. doi:10.1111/ans.13226
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