Contemporary management of drug-packers
© Kelly et al; licensee BioMed Central Ltd. 2007
Received: 18 December 2006
Accepted: 20 April 2007
Published: 20 April 2007
Experience with management of drug-packers (mules) is variable among different centres. However, despite a recorded increase in drug trafficking in general, as yet, no unified, clear guidelines exist to guide the medical management of those who only occasionally encounter these individuals. We describe our recent experience with this growing problem and discuss the most salient points concerning the contemporary management of body packers. Our recent experience demonstrates that type IV packages may now be managed conservatively for the most part.
Experience with management of drug-packers ("mules") is variable among different centres. However, despite a recorded increase in drug trafficking in general, as yet, no unified, clear guidelines exist to guide the medical management of those who only occasionally encounter these individuals.
Classification by category of packages used for ingestion by drug smugglers.
Categorical types of packages.
Loosely packed cocaine covered by two to four layers of condoms or other latex-like material. This type has the highest risk for leakage/rupture.
Tightly packed cocaine powder or paste covered in multiple layers of tubular latex
Tightly packed cocaine powder or paste covered by aluminium foil.
Types 1, 2 and 3 are radiolucent.
Dense cocaine paste is placed into a device, condensed and hardened. This is then packaged in tough tubular latex. This is then covered with coloured paraffin or fibreglass. It is always radiopaque, rendering it easily indentifiable on plain X-ray of the abdomen.
Ingesting multiple packets of drugs ("body packing") for the purpose of evading police detection is a well-described method of smuggling although the actual frequency is unknown, as most will go undetected. The process carries risks other than criminal charges. Acute drug intoxication due to rupture of the package(s) within the gastrointestinal tract leads to inadvertent over-dosage as the packages contain concentrated cocaine and can be fatal. Unlike heroin toxicity, there is no direct antidote for cocaine toxicity and the mortality rate after package leakage approaches 60% .
While it is clear that small bowel obstruction is an obvious indication for surgical removal, the indications for premptive surgery to obviate the risk of rupture have changed in recent years as body packers have developed more sophisticated packaging methods. McCarron and Wood initially detailed the three different types of cocaine packaging to which has been added a fourth type by Pidoto et al. . Therefore while initial recommendations strongly advocate early surgery once the diagnosis is apparent, these were based on experience with type I and II body packers with their high and unpredictable risk of package leakage/rupture. With the development of type III packets, a more conservative medical management was adopted and later publications counsel observation unless symptoms develop. The tough exterior of type VI packaging makes the risk of leakage/rupture very low and so its popularity with body packers has increased.
The standard examination for detection and surveillance is plain X-ray of the abdomen in an upright and a supine position. Depending on the purity of the drug, three different forms of attenuation have been described for types I-III: hashish is denser than stool; cocaine appears similar to stool; and heroin has a gaseous transparence. Computed tomography is occasionally used but nevertheless described as a very accurate diagnostic tool. Ultrasound and MR imaging do not play an important role. Regular urine analysis may reassure regarding the safety of this approach. Prolonged observation may be required as the packers often take bowel constipaters to avoid defecation at inopportune times during their journey.
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