Original contribution
A new method of packaging cocaine for international traffic and implications for the management of cocaine body packers

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Abstract

Clinical outcome of cocaine body packers is considered to be unpredictable and there are no clear guidelines for the management of these patients. Their surveillance in casualty wards, where they are usually admitted during evacuation of the packets, can be very difficult. The authors refer to a new type of cocaine packet, allowing these patients to be managed with a more conservative approach than in the past, and report their experience with 161 body packers, observed from January 1999 to December 2000. They adopted a surveillance protocol providing only minimal medical intervention. Among 161 body packers, 142 (88.2%) evacuated the ingested packets without significant symptomatology. Warning symptoms were present in 19 (11.8%) patients. Three patients (1.9%) presented with marked anxiety but none had cocaine in the urine sample. Fifteen (9.3%) body packers complained of colicky pain, and all underwent plain X-ray studies of the abdomen. Ten (6.2%) of them without radiologic signs of intestinal occlusion recovered with food deprivation and medical treatment, while five (3.1%) underwent laparotomy, three patients (1.9%) for gastric occlusion and two (1.2%) for ileal occlusion. Only one patient (0.6%) had warning symptoms and a urine screen positive for cocaine metabolites. In three cases of gastric occlusion, a gastrotomy was accomplished. In two cases of ileal occlusion, and in the patient with cocaine intoxication, packets were milked into the cecum, and some into the descending colon and rectum, until anal expulsion, by gentle pulling. Type 4 packets represent a new method of cocaine packaging, carrying the possibility of treating these body packers more conservatively than those transporting previous type of packets. Surgical approach to intestinal occlusion also may be conservative, because distal propulsion of the packets can be accomplished without entering the intestine.

Introduction

The term cocaine “body packer” (BP) refers to a person ingesting large numbers of cocaine-filled packets along with a constipating agent, in an attempt to pass undetected through customs. Later, these packets are expelled and the contents recovered. This practice, while becoming more and more popular in the last decades, may have disastrous consequences, such as acute drug intoxication or intestinal occlusion, both included in the term “body packer syndrome” (BPS) 1, 2, 3.

The first reports of people smuggling drugs wrapped in packets, and concealed either by swallowing or by insertion into the rectum or vagina, were published during the 1970s. Although rupture incidence in large series is not reported, there is a mortality rate as high as 56% after packet leakage or rupture, followed by acute drug intoxication (most frequently cocaine overdose) 1, 4, 5, 6, 7, 8, 9. Since these early reports, international smugglers have constructed new cocaine packets, more and more resistant to breakdown or leakage. In a large series, the rate of cocaine overdose due to packet rupture or leakage is now reported to be lower than 3% (10). No data are available on intestinal occlusion risk but it has likely remained constant over time, under 5% 2, 3, 10.

On the initial experience with the so-called type 1 and 2 packets, some authors advocated surgical treatment of all body packers, because of the high and unpredictable risk of rupture or leakage of the cocaine packets (1). With the discovery of a type 3 packet, the usual approach to these patients began to be a conservative medical management during the spontaneous evacuation of the packets 2, 3. At the same time, the usual methods of preventive gastrointestinal decontamination (ipecac syrup, lavage, enemas, and cathartics), as well as the endoscopic retrieval of cocaine packets, all included the possibility of packet rupture and were, therefore, no longer recommended 1, 11, 12, 13, 14. When surgical treatment was requested, multiple incisions into an unprepared intestine were invariably required, as the packets were found widely dispersed in the gut 2, 3.

Additionally, the management of BPs may be very difficult because these patients are often uncooperative and clear guidelines are not available. Occasionally, the risk of packet rupture and cocaine intoxication may be overestimated and medical or surgical measures taken out of proportion to the real risk. On the other hand, in Emergency Departments (EDs), where BPs are more frequently observed, there is a need for low cost management, able to detect possible complications in a timely fashion.

A new “mini-industrial” method of packaging cocaine for illegal international transport has been observed for the past few years in our ED. When examined, the new cocaine packet, which can be described as type 4, is much more resistant to rupture or leakage than previous ones.

Since the first observation in November 1997, we suspected that this innovation could enable the possibility of a more conservative approach to management than in the past. In January 1999, we were authorized to start a new surveillance protocol for cocaine BPs. The aim of the present study is to report the results of a 2-year experience in managing these patients.

Section snippets

Patients and methods

In December 1998, we submitted to the Ethical Committee of our institution a surveillance protocol for BPs, brought to our observation by custom agents. The protocol consisted of:

  • housing of the patients in a separate room of the casualty ward of our ED under continuous control of custom agents;

  • detection of the packet type on initial X-ray study and the first evacuation;

  • check-up with electrocardiogram (EKG) and routine blood tests;

  • normal hospital diet;

  • no use of drugs or preventive measures,

Results

From January 1999 to December 2000, 161 cocaine BPs were admitted to the casualty ward of our ED. Their average age was 32.7 years (range 18–59), with a male/female ratio of 2.3 (113 male and 48 female). On admission, a plain X-ray study of the abdomen, EKG and routine blood tests were accomplished on all patients, as in the above protocol. The outcome of the patients is summarized in Table 1.

During surveillance, 142 (88.2%) body packers evacuated the ingested packets spontaneously without

Discussion

Potential lethal consequences may come from the rupture of one or more cocaine packets into the intestine. Transmucous absorption of cocaine is quick and massive. The lethal dose per os (p.o.) is 1200 mg and the LD50 is 500 mg. A packet usually contains from 5–10 g of cocaine. There is no cocaine antidote to counteract this occurrence. Cocaine toxicity is initially characterized by marked anxiety, tachycardia, and mydriasis. Soon after neuropsychologic alterations, hyperpyresia, seizures,

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