Packers, Pushers and Stuffers - Drug Concealment in the ED

Although these terms may be heard more often in a Build-a-Bear factory or a kitchen at Christmas than a Emergency Department, it doesn’t mean they’re any less relevant. What on earth do these terms mean though and how are they relevant to our practice?

These terms relate to varying methods of drug concealement, each having different associated risks and management strategies. Working in a busy city centre ED like St. Emlyns we often see patients presenting with the effects of ilicit drug use or more concerningly with drugs they are trying to conceal in various bodily orifices. This is only becoming more prevalent, with drug trafficking offenses increasing by 32.9% from 2020 to 2021¹, and a 72% increase in drug related deaths from 2011 to 2020, with a sustained increase year on year since 2012¹.

Packers: Think “packed full to the brim”. This relates to individuals who ingest large quantities of drugs as a method of concealed transportation, usually across borders and are often referred to as “drug mules”. This method of concealment is often associated with sophisticated wrapping techniques and other methods to avoid detection, such as co-ingestion of constipating agents and antiemetics. As border control detection becomes more successful, cases of body-packing using children and pregnant women are on the rise. One government statistic found that 1,173 children were enslaved by drug dealers in 2019, comprising the majority of those trafficked into the drug business in that year².

Pushers: Think “pushed up”. This involves smaller quantities of drugs being inserted into cavities, such as the rectum or vagina.

Stuffers: Think “stuff your face”. This relates to individuals who hurriedly ingest small quantities of drugs when coming into contact with law enforcement in an attempt to avoid arrest. Generally this relates to small packages intended for personal use, and are likely to be more crudely wrapped.

Managing these patients can be tricky but thankfully RCEM have provided guidance which we can use in their management³.

Click to access Management_of_Suspected_Internal_Drug_Trafficker_December_2020.pdf

How might they present?

Asymptomatic: Current police and border force policy is to present detainees suspected of drug concealment to the ED, following several cases of drug related deaths in police custody.

Symptomatic: In cases of package perforation, this largely depends on which drug has been ingested or concealed. Patients will present with symptoms fitting with the drug type (see box 1). Packers are also at increased risk of bowel obstruction, ileus and perforation, and so may present with evidence of an acute surgical abdomen.

Sympathomimetics e.g. cocaine	Opiates e.g heroin
Tachycardia Hypertension Hyperpyrexia Dilated pupils Convulsions Agitation Chest pain Arrhythmias Nausea/ Vomiting Abdominal pain	Bradycardia Hypotension Hypothermia Miosis Respiratory Compromise CNS depression Pulmonary Oedema

Table 1: The common toxidromes seen in symptomatic patients⁴.

What are the imaging options?

Current RCEM guidelines advise a low dose CT (LDCT) as the primary investigation of choice. However, CT has limitations due to its cost, availability and radiation exposure. A recent paper by Malhotra and Singh (2021)⁵ has reviewed the literature on the various imaging modalities available in the ED, which is summarised below, including some additional findings and images from other literature.

CT

Sensitivity/Specificity	Pros	Cons
Reported sensitivity and specificity 95-100% regardless of drug type, wrapping material or packet number⁵.	– Can identify both quantity and location of packets which has important clinical and legal implications. – Can utilise Houndsfield units to identify the type of drug.	– Radiation risk can lead to legal implications – Takes more time to perform and interpret – Utilises more resources – Can be impacted by increased bowel contents, bowel gas and hardened faeces – Some studies report lower sensitivity in stuffers than in packers due to reduced packet number and size

**Image** 1: CT examples of drug packing⁶ from Knipe et al. Body packing. Reference article, Radiopaedia.org, Last revised 2019

X-Ray

Sensitivity/Specificity	Pros	Cons
Large variation in reported sensitivity, from 45%-100%^6,7. Suggested specificity of >90%.	– Quick – Low radiation – High detection rate – Easy availability	– Sensitivity can be impacted by hardened stool – Sensitivity is significantly decreased if less than 12 packets are present – Variable sensitivity depending on drug and wrapping type – May be impacted by techniques such as ingestion of substances with a similar radiographic density as small intestinal content, such as water or oil. – Less sensitive and specific for liquid containing packets

**Image 2:** Example plain radiograph of drug packing, including important signs^4,6
Knipe et al. Body packing. Reference article, Radiopaedia.org, Last revised 2019

Ultrasound

Sensitivity/Specificity	Pros	Cons
Sensitivity 91%, Specificity 70% Correct identification of presence or absence of packets in 87% of cases⁸.	– Easily accessible – Cheap – No radiation – Can be used in pregnant women and children – Has been found to have value in detecting packets inserted into the vagina	– Highly user dependent – Unable to differentiate type and quantity of drug which can have clinical and legal implications – Requires expertise – Specificity decreased by bowel gas and contents

Ultrasound Images are unfortunately not available due to permission issues, however the key signs to look out for are⁴:

Hyperechoic superficial surface with lack of posterior penetration

Reverberation artefact due to air between wrapping layers

What are the current RCEM guidelines for assessment and management?

The current guidelines are based on the method of drug concealment and whether symptoms are present. They give focus to using ToxBase as a management guide. The difficulty here lies in the reliance on the patient’s full disclosure. Obviously, this may not always be present, for a multitude of reasons, including fear of law enforcement or of higher level figures in the drug supply chain.

Suspected cocaine toxicity	Suspected opiate toxicity
– Urgent surgical referral for package removal (CT should not delay surgical intervention). – If hypertensive: use benzodiazepines and nitrates as per ToxBase – If QRS prolongation: use sodium bicarbonate as per ToxBase – Often requires anaesthetic input for early sedation to manage the hyper-adrenergic effects.	– Use generous amounts of naloxone and consider a naloxone infusion – If symptoms are managed using naloxone, this may avoid the need for surgical intervention.

Table 2: Specific approaches to management in cocaine and opiate toxicity³.

What are the medicolegal implications?

Intimate examination: Police may request an intimate examination of the patient. This is discouraged by RCEM due to the risk of injury to the patient or examiner, accidental package perforation, and may not reveal deeply located packages^3,7.
Specific imaging: Police may request an x-ray or ultrasound as a criminal investigation tool. Clinicians are not required to request these, even with consent from the patient^3,7.
Patient consent:
- Patients should be informed that a LDCT may not be therapeutic in nature and may be used as evidence in a criminal investigation. On the other hand, a negative LDCT may expedite their release from police custody³.
- All patients with capacity have a right to refuse investigations and discharge themselves from the hospital even though they are under arrest. Document fully what the patient has been told about their risks³.
Discharge information: On discharge of patients, a confidential medical summary detailing all relevant investigations and treatment should be provided in a sealed envelope marked for the attention of the custody healthcare professional. They should be made aware of the number of packets identified on LDCT and the number passed during observation. Also provide advice on the clinical signs of toxicity. Record who you have given this advice to. The patient should be informed of the medical handover³.

The take home messages:

Be vigilant! Not all patients with internally concealed drugs will present with the police or border force, not all of them will be forthcoming with information and not all of them will be symptomatic.
Scan with consent. The mainstay of imaging currently is a low dose CT, however this requires consent. Without consent, the general guidance is to observe then discharge to the police.
ToxBase is key. Current RCEM guidance focuses around using ToxBase for investigation, treatment and observation guidelines. This relies on patient candour, however in symptomatic patients the generic toxidrome can give direction as to which drug has been concealed,
Early surgical input should be sought in cases where there is a suspicion of obstruction, perforation or cocaine toxicity.
Communicate with, but don’t be directed by, the police. You are not obliged to perform intimate examinations or additional imaging if requested by the police. Provide a safe handover of information with safety netting advice.

Molly Bowman

References:

Allen & Tunicliffe, ‘Drug Crime: Statistics for England and Wales’, House of Commons Library, 2021
McDonald, ‘Over 1,100 children trafficked into UK drug trade, data shows’, The Guardian, 2020
Aw-Yong, Grundlingh, Andi, ‘Management of Suspected Internal Drug Trafficker’, RCEM Best Practice Guideline, 2020
Berger et al, ‘Body packing: A review of general background, clinical and imaging aspects’, Emergency Radiology, 2014
Malhotra & Singh, ‘Imaging of drug mules’, Emergency Radiology, 2021
Knipe et al. Body packing. Reference article, Radiopaedia.org, Last revised 2019
Booker, Smith & Rodger, ‘Packers, pushers and stuffers—managing patients with concealed drugs in UK emergency departments: a clinical and medicolegal review’, Emergency Medicine Journal, 2009