Substance abuse: routes,

hazards and body packing

Allister Vale
Abstract
Substances taken to alter the mental state may be ingested, inhaled,
absorbed through mucous membranes or injected. Accidental overdose
is common. Complications result either from the presence of contami-
nants or from the pharmacological actions of the substance(s) involved;
these include respiratory, neurological, renal and metabolic complica-
tions. Body packers often swallow large numbers of packages in the
hope of financial gain. Acute intestinal obstruction may result and over-
dose is a hazard if a packet bursts. Immediate surgery is indicated if
acute intestinal obstruction develops, or when packets can be seen radio-
logically and there is clinical or analytical evidence to suggest leakage,
particularly if the drug involved is a central nervous system stimulant
(e.g. cocaine).
Keywords acute intestinal obstruction; body 'packer'; body 'pusher';
body 'stuffer*; contaminants; 'Parachuting'
Substances
Many substances, some obtained from natural sources, are taken
to alter the mental state of the user. These include amfetamines.
Ecstasy, cannabis, cocaine, ethanol, ketamine, y-hydrox-
ybutyrate, lysergic acid diethylamide (LSD), mushrooms, opioid
analgesics, nitrites and other volatile substances.
Such substances can be classified according to whether their
major effect is to alter perception, or to stimulate or depress the
central nervous system (CNS), though there is some overlap
between groups. Substances that predominantly depress the CNS
(e.g. ethanol) may, for example, arouse and disinhibit behaviour
before exerting their principal action. Other drugs that initially
stimulate the brain may impair consciousness if taken in suffi-
cient quantities.
Routes of abuse
Substances may be ingested, inhaled, absorbed through mucous
membranes or injected.
Ingestion
Ingestion is convenient, but absorption is relatively slow and the
impact of the drug on the brain is correspondingly decreased,
unless large quantities are taken. Drugs taken by ingestion to
alter the mental state include anticholinergic drugs and plant
Allister Vale MO FRCP FKPC FKPC FFOM FAAcrFBts is Director of the National
Poisons Information Service (Birmingham Unit) and the West Midlands
Poisons Unit at City Hospital, Birmingham, UK. Competing interests:
none declared.
preparations, benzodiazepines, clomethiazole, ethanol, opioid
analgesics (particularly codeine and dihydrocodeine) and
sympathomimetics.
inhalation
Inhalation allows more rapid absorption of cannabis, cocaine,
nicotine, opiates, organic nitrites (e.g. isobutyl nitrite) and
volatile substances. Volatile substances are usually 'bagged'
(sprayed into a plastic bag and inhaled until the individual loses
consciousness) or 'huffed' (sprayed onto a cloth held to the
mouth). An abuser may attempt to enhance the intoxicant effects
by placing a plastic bag over the head.
Absorption tiirougii mucous membranes
Absorption through mucous membranes ('snorting' or 'snuffing')
is the method most commonly used with cocaine. The drug is
sniffed into the nostrils, where it is absorbed.
injection
Injection subcutaneously ('skin-popping'. Figure 1) or intrave-
nously ('mainlining'. Figure 2) is the fastest method of delivering
drugs to the brain in high concentrations. Intravenous injection is
the route preferred by most abusers for the more potent opioid
analgesics. Some heroin abusers inject metallic mercury after
heroin in the false hope of enhancing the 'high' (Figure 3).
Hazards of abuse
Accidental overdose is possible, though the degree of risk
depends, to some extent, on the route of administration. Intra-
venous injection carries the greatest risk, because some users are
inexperienced at injection technique and because there may be
unexpected increases in the potency of street drugs. Because
substance abuse is usually illegal, even unconscious or seriously
ill individuals may not be referred immediately for medical help,
and may be simply observed by their fellow substance abusers
until they improve or deteriorate so far that their condition can
no longer be ignored. Irreversible brain damage may result.
In addition, complications may result either from the presence
of contaminants or from the pharmacological actions of the
substance(s) involved. These include respiratory,' neurological,^
Figure 1 Erythematous skin lesions over the lower abdomen and iliac
crests, resulting from 'skin-popping'.
46 Africa Health July 2012
Figure 2 The left inguinal region of a man showing a localized depression
and fissure resulting from repeated use of t he femoral vein for intrave-
nous injection.
renal"* and metabolic"* complications. The complications of newer
recreational drugs have been reviewed.'
Contaminants
Some complications of abuse result from deliberate addition of
substances (e.g. quinine, talc) to dilute ('cut') the drug before it is
sold.*" In other cases, contaminants are introduced when the drug
is prepared for injection (e.g. passage through cigarette filters or
cotton wool). Particulate contaminants cause long-term,
progressive granulomatous pulmonary lesions.*" Other contami-
nants, particularly quinine, may be responsible for some of the
more acute toxic phenomena seen, and possibly even death.''
Other hazards
Other hazards of substance abuse include:
infection with hepatitis B, C and D virus and HIV^
injection site abscess caused by infection or leakage of
drug into the tissues
bacterial infections, including anthrax'^ and tetanus'"
candidiasis
inadvertent intra-arterial injection, leading to digital
gangrene (Figures 4 and 5).
Figure 4 A gangrenous forefoot resulting from intra-arterial injection of
drugs.
Body paci<ing and stuffing
Body 'packers' (sometimes called 'mules' or 'swallowers') are
those who swallow a substantial number of packages containing
illicit drugs for the purpose of smuggling." Heroin used to be the
drug of choice but this has been superseded by cocaine,'^ though
most deaths at least in New York are opiate-induced.'^ Accom-
plices have been known to remove packets after death.'''
Four different types of packaging have been described,'^
though packets are now usually machine manufactured result-
ing in uniformity in size and weight. Although each package
contains a potentially lethal amount of drug current materials
usually do not leak. Body packers may ingest up to 100-200
packages. In the case of cocaine, packages contain approximately
512 g. Body packers sometimes ingest anticholinergics such as
diphenoxylate/atropine to inhibit intestinal molity, thus
reducing potential defecation during the journey and subsequent
loss of drugs or discovery en route. The packages can cause
gastrointestinal obstruction and this complication can arise
regardless of the ingested agent and in the absence of package
leak. The use of constipating agents increases the risk of
obstruction.
Figure 3 Metallic mercury injected after heroin.
Figure 5 Ischaemic hand and fingers resulting from intra-arterial injection
of an opioid. The tourniquet had been placed around the palm of t he
hand, excluding the thumb. The injection was made into one of the digital
arteries, under such pressure that the injected material was flushed back
into the palmar arch, from where it was distributed to ail the digits.
July 2012
Africa Health 47
Substance Abuse
In contrast, body 'stuffers' are those who swallow a small
number of packages containing an illicit drug, usually heroin,
cocaine, cannabis or an amfetamine, in an unplanned attempt to
conceal evidence when on the verge of being arrested. These
drugs are usually either unpackaged or poorly packaged and as
a consequence leakage may occur over the ensuing 3-6 hours and
cause significant symptoms. Some also hide illicit drug packages
in their rectum or vagina with the same intent (these are some-
times known as body 'pushers'). Drugs hidden by pushers in the
vagina or rectum are less likely to cause significant symptoms, as
they are not subject to the digestive system. 'Parachuting' is
a technique of recreational drug use in which drugs are ingested
by wrapping them in a covering that is expected to dissolve or
unravel in the gastrointestinal tract and release the drug for later
absorption. Such patients should be managed in the same way as
body stuf fers.
Management
Imaging is used to investigate suspected complications of drug
concealment in a symptomatic individual and to detect drug
packages in an asymptomatic individual. Its use is confined
largely to body packers; imaging has a limited or no role in the
care of body stuffers/pushers. All patients suspected of body
packing should undergo abdominal CT as soon as possible.
Ultrasound is of similar accuracy to abdominal X-ray and far less
accurate than CT.
A urine screen for drugs of abuse should be performed on
admission. A screen that is positive for one or more drugs of
abuse suggests that either the patient has abused the drug in the
previous few days, or at least one packet is leaking. A negative
screen strongly suggests that no packet is leaking. Screens should
be repeated daily, or immediately if the patient develops features
of intoxication, to confirm the diagnosis.
With the introduction of improved packaging, immediate
surgery is not required unless symptoms develop; there is
a complication rate of less than 5% with this approach."''''
Immediate surgery is indicated if acute intestinal obstruction
develops, or when packets can be seen radiologically and there is
radiological, clinical or analytical evidence to suggest leakage,
particularly if the drug involved is a CNS stimulant (e.g.
cocaine).'^ In these circumstances, the clinical consequences of
poisoning are more serious and management is more difficult
than for opioids (for which an infusion of naloxone can be
given). A high rate (40%) of postoperative wound infection has
been found, which was correlated with the number of enter-
otomies.'^ It is recommended that investigations are performed
postoperatively to exclude missed packages.
Packets that remain in the stomach have been retrieved by
endoscopy and by inducing emesis, but these are potentially
dangerous procedures and are best avoided. Optimal manage-
ment of patients with packets in the small bowel is uncertain and
conservative strategies have their advocates.'^ If there is no
clinical, analytical or radiological evidence to support leakage,
the use of sorbitol or lactulose, with or without bowel stimulants
(e.g. bisacodyl) to encourage transit through the gut, is
successful in many cases. Alternatively, for faster results, whole-
bowel irrigation using polyethylene glycol electrolyte solutions
can be used.^ Liquid paraffin should not be used because it can
weaken rubber, leading to bursting of the packets. Activated
charcoal has been advocated by some, but induces constipation
when used in substantial doses to surround a large number of
packages, and is therefore contraindicated.
Packets in the colon or rectum are probably best managed by
giving sorbitol or lactulose and allowing them to pass sponta-
neously, with least risk of rupture. Packets in the vagina can
usually be removed manually and with ease.
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48 Africa Health July 2012
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