Acute ingestion of illicit drugs (body stuffing)

INTRODUCTION — Oral ingestion of drugs of abuse to evade detection occurs in two distinct patterns: "Body packing" is the planned and relatively well-coordinated ingestion for the purposes of smuggling [1,2], and "body stuffing" is the hasty ingestion of drugs in order to evade law enforcement [3,4].

Body stuffing is a distinct syndrome from body packing. The body stuffer is often at risk for acute toxicity because the drugs are usually unwrapped or poorly wrapped and not designed for ingestion and transport. Body stuffers usually ingest smaller amounts (grams) intended for individual sale, compared with body packers, who tend to ingest packets that contain a large quantity of drug (approximately 1 kg) [2]. If a packet ingested by a body packer ruptures, severe toxicity is likely, whereas a much larger number of body stuffing packets must be ingested for comparable toxicity to develop. Body packers are discussed separately. (See "Internal concealment of drugs of abuse (body packing)".)

The diagnosis and management of body stuffing is reviewed here. The toxicities of specific agents commonly abused or ingested are discussed separately.

●(See "Initial management of the critically ill adult with an unknown overdose".)

●(See "Cocaine: Acute intoxication".)

●(See "Methamphetamine: Acute intoxication".)

●(See "Acute opioid intoxication in adults".)

EPIDEMIOLOGY — Little data are available to provide insight into the scope of the body stuffing problem. However, cases are frequently seen in urban centers where the use of illegal drugs is common. Packaging methods for body stuffers vary widely among different regions [5-8]. Knowledge of local packaging techniques is essential to assess the potential risk of rupture and drug toxicity. Many drugs of abuse are "stuffed" with cocaine, heroin, and methamphetamine among the most common [5,9,10].

DIAGNOSIS — The diagnosis of body stuffing is made either by history or by appreciating signs and symptoms of drug toxicity without a clear history of ingestion. Body stuffers generally develop symptoms and signs of toxicity within hours of ingestion [5,11-13]. Any patient who presents to an emergency department or other clinical setting after being arrested for a drug charge and who rapidly develops characteristic sympathomimetic or opioid toxicity should be suspected of body stuffing [5,9]. Law enforcement officials should recognize the potential for ingestion when making drug arrests [14], as deaths have occurred among incarcerated individuals [8,15,16]. Clinicians should consider body stuffing in incarcerated individuals brought for medical evaluation.

HISTORY — When assessing a patient suspected of body stuffing, important questions to ask include:

●When was the drug ingested?

●How many packets were ingested?

●What drug and formulation (eg, powdered versus crack cocaine) were ingested?

●Were the packets wrapped? If so, how were they wrapped and what materials were used?

●Has the patient experienced symptoms of gastrointestinal obstruction or distress?

If the patient is in police custody, the history may not be forthcoming or accurate, and objective signs may be of greater importance.

In particular, it is important to obtain specific details about wrapping, which is a key factor in drug absorption. The packaging and method of wrapping has been shown to effect cocaine release in a simulated gastric medium [11]. One wrapping method involves using the corner of a sandwich bag to hold powder or rock cocaine (picture 1), then securing the bag by folding it over once or twice (picture 2). Another common packaging method in the United States consists of placing crack cocaine or heroin in a small Ziploc-style bag. These single layer packets will release drug over time (picture 3). It is important to inquire if one bag was placed in a larger bag (picture 4), as this will make the package less permeable and may increase the risk for gastrointestinal obstruction [17]. In general, paper decomposes rapidly (usually within one hour), while doubly wrapped plastic bags will elaborate drug more gradually [11]. Unwrapped contraband may yield clinical effects within 30 minutes to three hours [18].

PHYSICAL EXAMINATION — Physical examination of a body stuffer, either known or suspected, should focus on signs of drug toxicity, intestinal obstruction, and the location of packets. Body stuffers generally develop symptoms and signs of toxicity within hours of ingestion.

Cocaine is commonly ingested by body stuffers. Therefore, clinician should be alert for signs of the sympathomimetic toxidrome, which often includes hypertension, tachycardia, diaphoresis, agitation, tremors, seizures, hyperthermia, and dilated pupils [12,16,18]. Methamphetamine is commonly ingested in some regions and produces symptoms and signs similar to cocaine [10]. Ingestion of heroin or other opioids causes a toxidrome that often includes central nervous system depression, hypoventilation, miosis, and decreased bowel sounds [9]. The clinical presentation and toxicities associated with these drugs are discussed in detail separately. (See "Cocaine: Acute intoxication", section on 'Clinical manifestations' and "Methamphetamine: Acute intoxication", section on 'Clinical features' and "Acute opioid intoxication in adults", section on 'Clinical features of overdose'.)

Intestinal obstruction from body stuffing is rare but potentially dangerous. Clinicians should look for signs of obstruction, such as vomiting, decreased flatus, high-pitched (or absent) bowel sounds, abdominal distension, and abdominal tenderness.

Body stuffers may place drugs in orifices and locations other than the gastrointestinal tract. In hurried attempts to evade arrest, individuals may accidentally aspirate rather than swallow a packet, leading to respiratory distress and clinical deterioration [3,19]. Packets have been recovered from the rectum and vagina [20]. In the United Kingdom, specialized forensic physicians trained in the evaluation and management of body stuffers inspect the mouth, nostrils, ears, umbilicus, foreskin, rectum, and vagina of suspects [14].

IMAGING

Approach to imaging — There is little evidence and no controlled studies to determine how best to use diagnostic imaging in body stuffers. Based upon limited observational evidence and our clinical experience, we typically do not perform diagnostic imaging of body stuffers if the history and clinical presentation are straightforward and consistent. However, we sometimes obtain a noncontrast computerized tomography (CT) scan if the history is unclear or it is important to determine if drug packets are present in the gastrointestinal (GI) tract. We do not routinely obtain plain abdominal radiographs unless there is concern for GI obstruction or perforation.

Plain abdominal radiography — Plain abdominal radiography is generally unhelpful in managing body stuffers and we do not routinely obtain such studies, unless there is concern for obstruction or perforation. Unlike body packers, in whom the sensitivity of abdominal radiographs approaches approximately 90 percent [2], body stuffers are not easily identified by abdominal radiography. In one series of 46 cocaine body stuffers, none of the 23 plain radiographs obtained were positive [5,21]. In another series of crack vial ingestions, only 9 percent of plain radiographs were positive [22]. In a series of heroin body stuffers, only 1 radiograph of 32 taken (3 percent) was positive, and in that lone case, metal staples were visible to help identify an unusual packet [9]. In one case series of body packers, plain abdominal radiography with Gastrografin oral contrast was used to detect and follow passage of packets [23]. This approach has not been investigated in body stuffers.

Computerized tomography — We do not routinely perform computed tomography (CT) to evaluate body stuffers if the history and clinical presentation are straightforward and consistent; however, CT can be useful if the history is unclear and there is a compelling need to determine if drug packets are present in the GI tract [24]. In such settings, we typically obtain a CT without oral contrast, although CT with oral contrast has also been used [25].

Several case reports have described the use of CT without oral contrast to identify ingested packets in body stuffers [5,26,27]. However, false negative studies have also been reported [17]. According to one observational study, the attenuation of a crack cocaine packet is 91 Hounsfield units [26].

One study using a simulated model of physiological bowel content with boiled rice noodles and ultrasound gels tightly wrapped in multiple layers of cellophane demonstrated high sensitivity and specificity [28], although it is unclear whether the results using this model can be extrapolated to the typical packaging of drug loosely wrapped in sandwich or Ziploc bags. In a volunteer study using simulated drug packets with attenuation of 78 Hounsfield units, CT without contrast identified only 60 percent of packets [29].

LABORATORY TESTING

Urine toxicology screening — The utility of performing toxicology screening in body stuffers remains uncertain. In many cases, packets are poorly wrapped, and drug is released and absorbed. In such cases, urine drug testing may help to identify the ingested substance. However, it is difficult to distinguish between a positive result due to recreational consumption from one due to drug liberated from an ingested packet.

In general, patients in whom symptomatic poisoning is suspected should undergo bedside glucose determination if there is any alteration in mental status, an electrocardiogram (to rule out any conduction abnormalities), and a urine pregnancy test (in women of childbearing age). Additional laboratory evaluation depends upon the ingested substance and the degree of toxicity. Please see the relevant UpToDate topics for details, including the following: (see "Cocaine: Acute intoxication" and "Acute opioid intoxication in adults" and "Methamphetamine: Acute intoxication" and "MDMA (ecstasy) intoxication").

MANAGEMENT

Decontamination — The use of gastrointestinal decontamination for body stuffers is controversial, and there are few clinical studies to guide management. We believe it is reasonable in most cases to administer a single dose of activated charcoal (1 g/kg; maximum dose 50 g) to asymptomatic body stuffers. In vitro evidence suggests that activated charcoal (AC) adsorbs cocaine well [30,31]. However, no clinical series have been conducted to assess its impact on patient outcome.

Although some researchers suggest the use of whole bowel irrigation (WBI) with polyethylene glycol electrolyte lavage solution (PEG-ELS) [32], this too, is controversial. We do not routinely suggest treatment with WBI in the management of body stuffers. Furthermore, WBI is contraindicated in body stuffers who are hemodynamically unstable or markedly symptomatic. Hypotension from any cause, as well as cocaine intoxication, impairs bowel perfusion, thereby increasing the risk of ileus and obstruction [33].

Although WBI has been shown to be safe and feasible in body packers, there is no such supporting literature for body stuffers. Case series of body stuffers treated with AC, WBI, or both, have not reported a clear benefit [5,9,12]. A retrospective study suggested that WBI was unlikely to be performed correctly (if at all) in body stuffers, even after a recommendation from a Poison Control Center [34].

Symptomatic patients

Cocaine and other sympathomimetic toxicity — Treatments for body stuffers demonstrating signs of sympathomimetic overdose should be initiated immediately. Benzodiazepines are an important treatment for many of the toxicities caused by cocaine or methamphetamine (eg, agitation, hypertension, hyperthermia). The clinical presentation and management of such toxicities are reviewed in detail separately. Tables summarizing the emergent management of cocaine and methamphetamine poisoning are provided (table 1 and table 2). (See "Cocaine: Acute intoxication", section on 'Clinical manifestations' and "Cocaine: Acute intoxication", section on 'Initial management' and "Methamphetamine: Acute intoxication", section on 'Clinical features' and "Methamphetamine: Acute intoxication", section on 'Management'.)

Opioid toxicity — Body stuffers demonstrating signs of opioid toxicity (eg, depressed mental status, hypoventilation, pinpoint pupils) should be treated immediately with intravenous naloxone. The initial dose is 0.05 mg in patients with spontaneous ventilations, and 0.2 to 1 mg in apneic patients. If the patient has ingested a large dose of heroin, larger doses of naloxone may be required. Dosing in such cases should be titrated to clinical response.

The clinical presentation and management of opioid toxicity, including the use of naloxone, is reviewed in detail separately. A table summarizing the emergent management of opioid poisoning is provided (table 3). (See "Acute opioid intoxication in adults", section on 'Clinical features of overdose' and "Acute opioid intoxication in adults", section on 'Management'.)

OBSERVATION AND DISPOSITION

Symptomatic patients — Patients not responsive to pharmacologic therapy given for signs of severe sympathomimetic or opioid poisoning may require surgical removal of retained packets and prompt surgical consultation should be obtained. Depending upon the intoxicants ingested, refractory signs in unresponsive patients may include hypotension or hypertension, tachycardia, hyperthermia, and profoundly altered mental status. (See 'Physical examination' above.)

Symptomatic patients who can be managed effectively without surgical intervention are admitted to a location capable of providing an appropriate level of physiologic monitoring for detecting any sign of deterioration. The appropriate setting is determined by the level of exposure (eg, amount of drug or number of packets ingested), the presence of any coingestants, comorbidities, the patient's clinical status, and the resources available. Patients with severe symptoms and signs or potentially dangerous ingestions are observed in an intensive care setting. Assistance from a medical toxicologist or poison control center may be needed to determine the appropriate level of monitoring. (See 'Additional resources' below.)

Asymptomatic patients — Asymptomatic patients should be observed for the development of signs and symptoms of drug toxicity. The optimal duration of observation is unclear, and recommendations range from 6 to 24 hours [5,12]. We discharge patients with an uncomplicated history of ingesting a small number of packets (fewer than 10) who remain asymptomatic after 6 to 12 hours of observation. Opioids can lead to gastrointestinal atony, which can complicate the course by increasing packet transit time [35]. Provided the patient remains asymptomatic, 6 to 12 hours of observation is usually sufficient in patients with delayed gastrointestinal transit.

In one series of 46 cocaine body stuffers, all eight patients who developed symptoms or signs of toxicity had some apparent abnormality upon arrival to the hospital [5]. However, another case report of a cocaine body stuffer describes the development of altered mental status, seizure-like activity, and a wide complex dysrhythmia 14 hours after ingestion [13]. A retrospective review reported no late complications among low risk cocaine body stuffers once they became asymptomatic [36]. Patients were considered low risk if they were asymptomatic, not in police custody, and were not body packers.

Patients with a concerning history or findings that put them at higher risk for severe toxicity should be admitted to an intensive care setting where they can be closely monitored for signs of deterioration. Monitoring should include frequent vital signs, pulse oximetry, cardiac monitoring, and end-tidal CO2 for early detection of apnea. Important things to consider when deciding on the appropriate disposition include the number of drug packets ingested and the method used to wrap the drugs. As an example, a history of consuming a larger bag containing many smaller bags, or ingesting a massive number of packets, suggests the need for a longer period of observation. In such cases, the clinician should ensure that all packets have passed the pylorus.

Another important factor to consider when determining disposition is whether a patient can return promptly for medical evaluation should the need arise, or whether a complicated and time-consuming jail transfer would be involved, placing the patient at additional risk.

When determining the appropriate observation period for all but the most straightforward cases, clinicians are encouraged to consult a medical toxicologist or contact a poison control center. (See 'Additional resources' below.)

ADDITIONAL RESOURCES

Regional poison control centers — Regional poison control centers in the United States are available at all times for consultation on patients with known or suspected poisoning, and who may be critically ill, require admission, or have clinical pictures that are unclear (1-800-222-1222). In addition, some hospitals have medical toxicologists available for bedside consultation. Whenever available, these are invaluable resources to help in the diagnosis and management of ingestions or overdoses. Contact information for poison centers around the world is provided separately. (See "Society guideline links: Regional poison control centers".)

Society guideline links — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Treatment of acute poisoning caused by specific agents other than drugs of abuse" and "Society guideline links: General measures for acute poisoning treatment".)

SUMMARY AND RECOMMENDATIONS

●Comparison with body packing – "Body packing" is the planned and relatively well-coordinated ingestion for the purposes of smuggling. "Body stuffing," the hasty ingestion of drugs in order to evade law enforcement, is a distinct syndrome from body packing. The body stuffer is often at risk for acute toxicity because the drugs are usually unwrapped or poorly wrapped, and not designed for ingestion and transport. Body packing is reviewed separately. (See "Internal concealment of drugs of abuse (body packing)".)

●Diagnosis – The diagnosis of body stuffing is made either by history or by appreciating signs and symptoms of drug toxicity without a clear history of ingestion. Any patient who presents to an emergency department or other clinical setting after being arrested for a drug charge and who rapidly develops characteristic sympathomimetic or opioid toxicity should be suspected of body stuffing. (See 'Diagnosis' above.)

●History – Although body stuffers may not provide an accurate history, clinicians should inquire about the type and amount of drug ingested, the number of and wrapping used for any drug packets ingested, and whether they are experiencing any gastrointestinal (GI) symptoms consistent with obstruction or perforation. Cocaine, methamphetamine, and opioids (eg, heroin) are among the drugs most commonly ingested by stuffers. (See 'History' above.)

●Physical examination – Physical examination of a body stuffer, either known or suspected, should focus on signs of drug toxicity, intestinal obstruction, and the location of packets. Signs of sympathomimetic or opioid toxicity are most common and are described in the text. Body stuffers generally develop symptoms and signs of toxicity within hours of ingestion. (See 'Physical examination' above.)

●Role of imaging – We typically do not perform diagnostic imaging of body stuffers if the history and clinical presentation are straightforward and consistent. However, we sometimes obtain a noncontrast computerized tomography (CT) scan if the history is unclear or it is important to determine if drug packets are present in the GI tract. We do not routinely obtain plain abdominal radiographs unless there is concern for GI obstruction or perforation. (See 'Imaging' above.)

●Management – Body stuffers should be treated aggressively based on signs of toxicity.

•Sympathomimetic toxicity – Benzodiazepines are an important treatment for many of the toxicities caused by cocaine or methamphetamine (eg, agitation, hypertension, hyperthermia) (table 1 and table 2). (See 'Cocaine and other sympathomimetic toxicity' above and "Cocaine: Acute intoxication", section on 'Initial management' and "Methamphetamine: Acute intoxication", section on 'Management'.)

•Opioid toxicity – Body stuffers demonstrating signs of opioid toxicity (eg, depressed mental status, hypoventilation, pinpoint pupils) should be treated immediately with intravenous naloxone. The initial dose is 0.05 mg in patients with spontaneous ventilations, and 0.2 to 1 mg in apneic patients (table 3). (See 'Opioid toxicity' above and "Acute opioid intoxication in adults", section on 'Management'.)

•Failure of pharmacologic therapy – A patient who is not responsive to pharmacologic therapy for signs of severe sympathomimetic or opioid poisoning may require surgical removal of retained packets. (See 'Symptomatic patients' above.)

●Disposition – Symptomatic patients who can be managed effectively without surgical intervention are admitted to a location capable of providing an appropriate level of physiologic monitoring for detecting any sign of deterioration. Asymptomatic body stuffers typically require approximately 6 to 12 hours of observation before they can be discharged safely. Body stuffers who have ingested packets with complicated wrapping or show signs of delayed gastrointestinal transit require longer periods of observation, and possibly imaging studies. (See 'Symptomatic patients' above and 'Asymptomatic patients' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Stephen J Traub, MD, former section editor of the toxicology program, for 20 years of dedicated service.