Packers, Stuffers, and Pushers

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Background

Body packers, stuffers, and pushers may present to the emergency department (ED) for evaluation of symptoms or for medical clearance before prosecution. It is important for the ED physician to have a keen framework for diagnosing, evaluating, and treating these patients.

Although similar sounding, there are significant, management-altering distinctions between these three entities - packers, stuffers, and pushers.

  • Body packing is the generally well-planned ingestion of wrapped drugs for the purpose of trafficking. This is what may be colloquially known as a “drug mule.”

  • Body stuffing is the hurried swallowing of either poorly packaged or unpackaged drugs to avoid prosecution.

  • Drug pushing is the hurried placement of poorly packaged or unpackaged drugs into the rectum, vagina, or other orifices to avoid arrest or for resale at a later time.

One study found that the mean intra-abdominal package count was 16 packets, with a maximum of 100 large packages in one body packer (approximately 1 kg of narcotics). Meanwhile, body stuffers typically transport drugs for personal use, a significantly lower number of packets than body packers (mean 8.7 vs 34.2, p<0.001) (1).

Gathering an accurate history from these patients can be challenging.  The presence of law enforcement agents nearby complicates the interview process and efforts should be made to form and protect a therapeutic relationship with the patient. Keeping law enforcement at the right distance to have eyes on the patient but be out of earshot can help with this.  Even still, these patients are often presenting with a looming threat of significant legal peril and may not be forthcoming with a history.

While an estimated 70% of these individuals will be male, it is important to note that victims of drug trafficking can be people of all sexes, ages, and ethnicities. One article published in the Emergency Medical Journal studied 1,250 subjects apprehended by the U.S. Customs officials at JFK Airport. The mean age of these individuals was 33 years of age and the most commonly transported substance was heroin (73%) (2).

History

These patients may present to the emergency department unconscious, endorsing a history of collapse, seizure, or abdominal pain. The ability to obtain a quick and accurate history from your patient will significantly affect the time to intervention. Here are some critical questions to clarify:

  • What type of drug was ingested?

  • When was the drug ingested?

  • How many packets were ingested?

  • How were the packets wrapped?

  • Has the patient had symptoms of gastrointestinal obstruction or distress?

  • Any co-ingestions?

Diagnostics

The physical exam is not a lost art in these patients! It can reveal many things about the ill-appearing or non-verbal patient in front of you - whether they have intestinal obstruction, a toxidrome, or packets in an obvious orifice. Exam findings of obstruction include emesis, high-pitched or absent bowel sounds, abdominal distension and sometimes palpable packets, and abdominal tenderness. If the patient’s abdomen reveals involuntary guarding, perforation should be suspected. If suspected, rectal and vaginal examinations may disclose packets. Additionally, identify the toxidrome taking place if there is one. Usually the toxidrome will be either sympathomimetic or opioid-related but it could present as a mixed toxidrome depending on the substances that were ingested.

As a refresher, symptoms of a sympathomimetic toxidrome include: hypertension, tachycardia, diaphoresis, hyperthermia, seizures, collapse

Symptoms of an opioid toxidrome include: bradypnea progressing to respiratory failure, miosis, decreased bowel sounds

Depending on the patient’s symptoms and presentation you can consider some diagnostics to aid in detection of end organ damage including - CBC, BMP, LFTs, lipase, VBG, troponin and EKG (if the patient complains of chest pain). Diagnostic radiographs such as a chest x-ray and abdominal x-ray may be able to identify packaged substances. However, if you are unable to visualize the number of packets or exact location of an obstruction on x-ray, CT imaging may be indicated. Of note, there is limited utility for a urine drug screen in these patients as it is poorly sensitive (an estimated 52% in detecting cocaine), does not tend to change management, and can be misleading (3).

Plain Film Radiographic Signs of Body Packing

Double-condom sign - Air trapping between layers of packet wrapping

Double-condom sign - Air trapping between layers of packet wrapping - Kumar, Surana Santosh, et al. “Diagnostic Radiographic Findings in Body Packers: A Study of 15 Cases in Kuwait.” The Internet Journal of Radiology, Internet Scientific Publications, 31 Dec. 2006, https://ispub.com/IJRA/6/2/11339.

Rosette sign - Air trapped in the knot where packaging is tied

Rosette Sign - Air trapped in the knot where packaging is tied (White Arrow) - Tsang, Ho Kai, et al. “Radiological Features of Body Packers: An Experience from a Regional Accident and Emergency Department in Close Proximity to the Hong Kong International Airport.” Hong Kong Journal of Emergency Medicine, vol. 25, no. 4, 2018, pp. 202–210., https://doi.org/10.1177/1024907918770083.

Tic Tac Sign and Parallelism Sign - Multiple stacked homogeneous radiopaque oval foreign bodies with sharp border

Parallelism Sign (Black Arrows) Tic Tac Sign (White Box) - Pinto, A, et al. “Radiological and Practical Aspects of Body Packing.” The British Journal of Radiology, vol. 87, no. 1036, 2014, p. 20130500., https://doi.org/10.1259/bjr.20130500.

Therapeutics

All management should begin with airway, breathing, and circulation. Management and disposition differs between packers and pushers/stuffers, as well as among symptomatic vs. asymptomatic patients. Considering the disposition of the 1,250 individuals apprehended in the initial study mentioned, 56 were admitted to a hospital. Of these, 45% required surgical intervention, while the rest were managed conservatively (2).

Asymptomatic Patients

Asymptomatic “packers” should be observed for development of drug toxicity. Recommendations for the duration of observation ranges from 6 to 24 hours from ingestion and may vary based on clinical practice guidelines at each hospital. Mainstay of therapy for those without intestinal obstruction includes whole bowel irrigation with polyethylene glycol via NG tube. After an observation period, patients can be considered “cleared” after two normal bowel movements and a normal abdominal X-ray (3). If the packets have not passed in 5 days, then surgical removal should be reconsidered.

The recommended disposition for asymptomatic patients with a history significant for stuffing/pushing is conservative management with monitoring in an ICU setting (4).

Symptomatic Patients

Treat the toxidrome. Sympathomimetic toxidromes should be treated with intravenous benzodiazepines. Treatment of the hypertension and hyperthermia that accompanies sympathomimetic toxidromes may require separate measures outside of IV benzodiazepine therapy. External cooling measures can be used for hyperthermic patients. IV antihypertensives may be needed for severe level hypertension. Opiate toxidromes can be treated with naloxone with consideration for continuous IV drips as opposed to bolus therapy. After stabilization of the patient, surgical removal of the drug packets will often be required. Surgical removal is often accomplished through laparotomy with careful attention to limiting the risk of rupture of drug packets (5).

Conclusion

  • The patient interview is a critical step in diagnosis. Utilizing an interpreter as appropriate and establishing a therapeutic relationship matters. Your history and physical exam matter.

  • Identify signs and symptoms of intestinal obstruction. Suspecting drug packing/stuffing will allow quicker evaluation, diagnosis, and disposition for your patient.

  • Conservative management will likely be the mainstay of therapy. Asymptomatic packers can likely be discharged after clearing the packets and having a clear abdominal x-ray. Asymptomatic stuffers may have to be observed in an ICU or step-down setting.

References

  1. Heymann-Maier, Liv, et al. “Emergency Department Management of Body Packers and Body Stuffers.” Swiss Medical Weekly, 2017, https://doi.org/10.4414/smw.2017.14499.

  2. Mandava N, et al. Establishment of a definitive protocol for the diagnosis and management of body packers (drug mules). Emerg Med J.2011 Feb;28(2):98-101.

  3. De Prost, Nicolas, et al. “Prognosis of Cocaine Body-Packers.” Intensive Care Medicine, vol. 31, no. 7, 2005, pp. 955–958., https://doi.org/10.1007/s00134-005-2660-y.

  4. de Prost N, Lefebvre A, Questel F, et al. Prognosis of cocaine body-packers. Intensive Care Med 2005;31:955–8.

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

  6. Silverberg D, Menes T, Kim U. Surgery for “body packers”—a 15-year experience. World J Surg 2006;30:541–6.

  7. Traub, Stephen J., et al. “Body Packing — the Internal Concealment of Illicit Drugs.” New England Journal of Medicine, vol. 349, no. 26, 2003, pp. 2519–2526., https://doi.org/10.1056/nejmra022719.

  8. Snow, Timothy E. “Treating the Convicted.” EMRA, 8 Oct. 2015, https://www.emra.org/emresident/article/treating-the-convicted/.

  9. 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.

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

Authorship

Written by: Saie Joshi, MD, PGY-1, University of Cincinnati Department of Emergency Medicine

Peer Review and Editing by: Jeffery Hill, MD MEd, Associate Professor, University of Cincinnati Department of Emergency Medicine

Cite As

Joshi, S. Hill, J. (September 13, 2022) Packers, Stuffers, and Pushers. TamingtheSRU. https://www.tamingthesru.com/blog/2022/9/12/packers-stuffers-and-pushers