Pusher, Packer, or Stuffer? A Case of Pediatric Drug Use

The Case

An otherwise healthy 15-year-old male presents to the ED in the custody of police for drug ingestion. The patient reported intentional ingestion of a plastic bag of heroin laced with fentanyl 45 minutes prior to arrival to avoid arrest by police.

The patient denies headache, palpitations, nausea, emesis, diarrhea, or abdominal pain. On exam, the patient is afebrile and vital signs are within normal limits. He is in no distress and is awake, alert, and oriented to person, place, and day. Pupils are 3 mm and respond equally to light. He is breathing comfortably and has no abdominal pain on palpation. His skin is warm and dry.

What is the term used to describe this patient’s ingestion?

  1. Body Packing
  2. Body Stuffing
  3. Body Pushing
  4. Body Filling
Body Stuffer

Background

Concealment of illicit drugs in the body can be divided into “body packing” and “body stuffing.” (1) 

Body packing is the prearranged and generally well-coordinated ingestion for the purposes of drug trafficking.

On the other hand, body stuffing is the hurried swallowing of drugs to avoid immediate arrest.

Body packers will carry approximately 1kg (2.2 lbs) of total drug, divided into 50 to 100 packets. (2) Each packet containing enough drug to be lethal. Meanwhile, body stuffers ingest smaller amounts, which are typically for individual use. The body stuffer is often at risk for acute toxicity secondary to the fragile wrapping of the drug product as the packing is typically not intended for ingestion and transport such as the wrapping often used for body packing. However, if the packet ingested by a body packer ruptures, severe toxicity is significantly more probable.

The incidence and epidemiology of body packing and body stuffing is not well characterized; however, the practices have been noted to cross age, gender, and ethnic groups. Based on retrospective reviews of body stuffers, males were more frequently involved than females and the mean age across studies was approximately 33 years old. (3) Unfortunately, the literature has noted that children have been involved in this type of drug concealment, with a 12-year-old child found to have ingested 84 packets of heroin. (4,5)

Evaluation

Body stuffers and body packers generally present to health care providers for drug-induced toxidromes, medical assessment after detention or arrest, or intestinal obstruction. The conditions under which the patient presents will often guide the workup and management. Notably, in pediatric patients, Child Protective Services should be involved early in the course.

Obtaining History

Key questions to obtain in the history, if possible, are:

  1. What type of drug was ingested?
  2. When was the drug ingested?
  3. How many packets were ingested?
  4. How were the packets wrapped?
  5. Has the patient had symptoms of gastrointestinal obstruction or distress?
  6. Any other ingestions?

Physical exam

Generally, the physical examination should evaluate for signs of drug toxicity, intestinal obstruction, and the location of packets. As opposed to body packers, who tend to have drug packets expertly fashioned, (6) body stuffers commonly develop evidence of toxicity within hours of ingestion. Notably, as packets tend to leak before they rupture, signs and symptoms linked to a specific toxidrome should be noted early in the exam to anticipate potential devastating outcomes.

For cocaine ingestion, a sympathomimetic toxidrome should be identified, which includes tachycardia, hypertension, anxiety, agitation, diaphoresis, mydriasis, and later in the course, hyperthermia, seizures, and cardiovascular collapse. (7)

For heroin ingestion, findings of an opiate toxidrome may be identified, including bradypnea, depressed mental status, miosis, and decreased bowel sounds. (8)

Intestinal obstruction and perforation are more common in body packers than body stuffers. (9) Exam findings of obstruction, include emesis, high-pitched or absent bowel sounds, abdominal distension, and abdominal tenderness. If the patient’s abdomen reveals involuntary guarding, perforation should be suspected.

In terms of location of the drug packets, the physical examination is often not helpful. If suspected, rectal and vaginal examinations may disclose packets. The abdominal examination may reveal distention or palpable packets.

Diagnostic testing

Recommended testing includes an electrocardiogram; baseline bloodwork of CBC, BMP, LFTs, amylase, and blood gas; and an erect chest radiograph and abdominal radiograph. (9,10) If the patient endorses chest pain, a troponin should be obtained given possible cocaine-induced ischemia. Urine drug screening is generally not recommended as it is poorly sensitive, does not tend to change management, and is often misleading. (1,11)

Imaging

A conventional radiograph should be obtained for all body packers. Specific findings include smooth, well-circumscribed foreign bodies that measure ~2.5cm, a “double condom sign,” and a “rosette-sign.” (12) However, because of the limited contrast resolution, its sensitivity for detecting drug packets ranges from 40–90% in body packers and significantly less so in body stuffers. (13,14)

 Example of the "double condom" sign. Air trapping between latex seen at arrows.  Credit: Dr. Frank Gaillard: http://radiopaedia.org/. Image obtained from Radiology Picture of the Day: http://www.radpod.org/2007/09/30/body-packer/. Image modified with arrows. This work is licensed under a Creative Commons Attribution-Noncommercial 2.5 License.

Example of the "double condom" sign. Air trapping between latex seen at arrows.

Credit: Dr. Frank Gaillard: http://radiopaedia.org/. Image obtained from Radiology Picture of the Day: http://www.radpod.org/2007/09/30/body-packer/. Image modified with arrows. This work is licensed under a Creative Commons Attribution-Noncommercial 2.5 License.

Generally, body stuffers do not require imaging. CT has been noted to be more sensitive than plain films for detecting drug packets and is often reserved for cases where abdominal plain films were negative but there is a high clinical suspicion for packing. In cases of suspected bowel obstruction, CT should be performed. Generally, oral and rectal contrast should be avoided as it can obscure packages because of similarities in density. (13)

Ultrasound has been proposed as an imaging modality as well, yet it has been noted to have a lower sensitivity than plain films. (12) Nevertheless, if perforation is suspected, ultrasound is an expedient way to determine if free fluid is present. 

Management

All management should begin with the ABCs.

Disposition differs significantly between body stuffers and body packers.

Body stuffers

  • Asymptomatic patients should be observed for development of drug toxicity.
  • Recommendations for the duration of observation ranges from 6 to 24 hours from ingestion.7,14 However, the literature is primarily based on adult patients.
  • Activated charcoal (1 g/kg, up to 50 g) has been proposed for acute ingestion given its in-vitro ability to adsorb cocaine; however, clinical evidence is limited. (15)
  • Whole bowel irrigation, often used and recommended for body packers,16 has not been supported in the literature for body stuffers and often is not recommended.
  • In cases that are not straightforward and more complicated cases, such as ingestion of more than 10 pockets, poor history of events, and symptomatic patients, a Toxicologist or the Poison Control Center (1-800-222-1222) should be consulted.
  • Patients who are symptomatic may require surgical removal of retained packets and prompt surgical consultation if there are signs of obstruction, perforation, or if the patient’s toxidrome is unresponsive to medical therapy.
  • If surgical intervention is not needed, symptomatic patients should be admitted to a monitored setting based on their clinical status.

Body packers

  • The recommendation for asymptomatic patients is conservative management with monitoring in an ICU setting. (1,9)
  • Early surgery was recommended in the past for asymptomatic patients; however, as packet production has improved, the rate of rupture has declined.
  • Whole bowel irrigation with polyethylene glycol via an NG tube at a rate of 2 L/hr should be instituted.
  • Patients are eligible for discharge if they are asymptomatic AND have passed 3 packet-free bowel movements AND there is no radiologic evidence of internal packets remaining. (9) 
  • Patients with opioid toxicity should be treated with naloxone and may require very high doses.
  • Doses of naloxone are 0.01 mg/kg for infants and children younger than 5 years old or weighing less than 20 kg. Otherwise, doses range from 2-5 mg initially.
  • Higher initial doses of naloxone may be required and doses should be repeated every (5) minutes until responsive.
  • The total amount required for responsiveness should then be given every hour as a continuous drip.
  • Body packers presenting with sympathomimetic toxicity should be taken to the operating room for exploratory laparotomy – there is no medical antidote. (1)
  • Pharmacologic therapy with IV benzodiazepines with rapid up-titration and sodium bicarbonate for wide-complex tachycardias may should be given as the OR is prepared.
  • Patient’s with obstruction or perforation should also be taken for exploratory laparotomy.
  • Of note, body packers (and to some extent body stuffers) in legal custody may refuse to undergo invasive examinations and radiography; however, in most cases, they cannot refuse being medically cleared and discharged. (1)

Case Conclusion

The patient was admitted to the Pediatric floor, where he remained for 7 days. He received whole bowel irrigation, remained asymptomatic, had >3 bowel movements without any evidence of a drug packet, and had a CT scan showing no specific abnormalities. He was subsequently discharged home with his family.

Faculty Reviewer: Dr. Jane Preotle

Resources

1.     Traub SJ, Hoffman RS, Nelson LS. Body Packing — The Internal Concealment of Illicit Drugs. N Engl J Med. 2003;349(26):2519-2526.

2.     Bulstrode N, Banks F, Shrotria S. The outcome of drug smuggling by “body packers”--the British experience. Ann R Coll Surg Engl. 2002;84(1):35-38.

3.     Philip R, Aidayanti D. Uncommon Sites for Body Stuffing: A Literature Review. 2014.

4.     Beno S, Calello D, Baluffi A, Henretig FM. Pediatric Body Packing: Drug Smuggling Reaches a New Low. Pediatr Emerg Care. 2005;21(11):744.

5.     Traub SJ, Kohn GL, Hoffman RS, Nelson LS. Pediatric Body Packing. Arch Pediatr Adolesc Med. 2003;157(2):174-177.

6.     Pidoto RR, Agliata AM, Bertolini R, Mainini A, Rossi G, Giani G. A new method of packaging cocaine for international traffic and implications for the management of cocaine body packers. J Emerg Med. 2002;23(2):149-153.

7.     Sporer KA, Firestone J. Clinical course of crack cocaine body stuffers. Ann Emerg Med. 1997;29(5):596-601.

8.     Jordan MT, Bryant SM, Aks SE, Wahl M. A five-year review of the medical outcome of heroin body stuffers. J Emerg Med. 2009;36(3):250-256.

9.     Alfa-Wali M, Atinga A, Tanham M, Iqbal Q, Meng A-Y, Mohsen Y. Assessment of the management outcomes of body packers. ANZ J Surg. 2016;86(10):821-825.

10.   Beckley I, Ansari NAA, Khwaja HA, Mohsen Y. Clinical management of cocaine body packers: the Hillingdon experience. Can J Surg. 2009;52(5):417-421.

11.    Bogusz MJ, Althoff H, Erkens M, Maier RD, Hofmann R. Internally concealed cocaine: analytical and diagnostic aspects. J Forensic Sci. 1995;40(5):811-815.

12.    Lee K, Koehn M, Rastegar RF, et al. Body packers: the ins and outs of imaging. Can Assoc Radiol J J Assoc Can Radiol. 2012;63(4):318-322.

13.    Pinto A, Reginelli A, Pinto F, et al. Radiological and practical aspects of body packing. Br J Radiol. 2014;87(1036).

14.   June R, Aks SE, Keys N, Wahl M. Medical outcome of cocaine bodystuffers. J Emerg Med. 2000;18(2):221-224.

15.   Tomaszewski C, Voorhees S, Wathen J, Brent J, Kulig K. Cocaine adsorption to activated charcoal in vitro. J Emerg Med. 1992;10(1):59-62.

16.   Position paper: whole bowel irrigation. J Toxicol Clin Toxicol. 2004;42(6):843-854.

Header image: Credit: Dr. Frank Gaillard: http://radiopaedia.org/. Image obtained from Radiology Picture of the Day: http://www.radpod.org/2007/09/30/body-packer/. Image modified with arrows. This work is licensed under a Creative Commons Attribution-Noncommercial 2.5 License.