Imaging of drug mules

Emergency Radiology - Cocaine, heroin, methamphetamine, and hashish are the primary drugs transported by a body packer, who swallows such packages. A body pusher or stuffer transports drug packages...     

Heroin body packer's death in Haryana; India: A case report

We report a case of death due to heroin leakage in a body packer, attempting to smuggle the drug by concealing it in his gastro-intestinal tract. The body was recovered 3–5 days of incidence that was confirmed by autopsy. Fifty pellets (packages) were recovered from the body, 42 identical oval shaped “egg” packages were found in the stomach out of which two were damaged, 6 in small intestine, 2 in large intestine. The total weight of the powder was 267 g. Toxicological analysis of the powder samples from the damaged package and other 48 packages was performed and was found positive for heroin, caffeine and codeine. The main pathological findings at autopsy were pulmonary and cerebral edema. This case illustrates the challenges in postmortem evaluation of narcotic fatalities and the need to consider factors such as ante-mortem history, thorough post mortem examination, toxicology results and photography in forensic diagnosis. This case is unique in the sense that cause of death was intoxication caused by leakage of heroin from damaged packages detected at autopsy and demonstrates that body packing is an existing problem in India.     

Death by ‘ice’: fatal methamphetamine intoxication of a body packer case detected by postmortem computed tomography (PMCT) and validated by autopsy

Fatal acute methamphetamine (MA) poisoning in cases of internal drug trafficking is rarely described in the literature. This case study reports an MA ‘body packer’ who died from fatal methamphetamine intoxication due to leaking drug packages in the alimentary tract. The deceased was examined by postmortem computed tomography (PMCT), and the results were correlated to subsequent autopsy and toxicological findings. The deceased was arrested by the police when he was found disoriented in the city of Kuala Lumpur. He was transferred to the emergency department on suspicion of drug abuse. The initial drug screening was reactive for amphetamines. Shortly after admission to the hospital, he died despite rigorous resuscitation attempts. The postmortem plain chest and abdominal radiographs revealed multiple suspicious opacities in the gastrointestinal tract attributable to body packages. An unenhanced whole body PMCT revealed twenty-five drug packages, twenty-four in the stomach and one in the transverse colon. At least two were disintegrating, and therefore leaking. The autopsy findings were consistent with the PMCT results. Toxicology confirmed the diagnosis of fatal methamphetamine intoxication.     

Differentiation of heroin and cocaine using dual-energy CT—an experimental study

Objective

To evaluate if heroin and cocaine can be distinguished using dual-energy CT.

Materials and methods

Twenty samples of heroin and cocaine at different concentrations and standardized compression (SC) were scanned in dual-energy mode on a newest generation Dual Energy 64-row MDCT scanner. CT number, spectral graphs, and dual-energy index (DEI) were evaluated. Results were prospectively tested on six original samples from a body packer. Wilcoxon’s test was used for statistical evaluation.

Results

Values are given as median and range. Under SC, the CT number of cocaine samples (?29.87 Hounsfield unit (HU) [?125.85; 16.16 HU]) was higher than the CT number of heroin samples (?184.37 HU [?199.81; ?159.25 HU]; p?<?0.01). Slope of spectral curves for cocaine was ?2.36 HU/keV [?7.15; ?0.67 HU/keV], and for heroin, 1.75 HU/keV [1.28; 2.5 HU/keV] (p?<?0.01). DEI was 0.0352 [0.0081; 0.0528] for cocaine and significantly higher than for heroin samples (?0.0127 [?0.0097; ?0.0159]; p?<?0.001). While CT number was inconclusive, all six original packs were correctly classified after evaluation of the spectral curve and DEI. In contrast to the CT number, slope of the spectral curve and DEI were independent of concentration and compression.

Conclusion

The slope of the spectral curve and the DEI from dual-energy CT data can be used to distinguish heroin and cocaine in vitro; these results are independent of compression and concentration in the measured range.     

Window manipulation in diagnosis of body packing using computed tomography

Body packing refers to the internal concealment of narcotics, usually within the gastrointestinal tract. This is important to recognise for clinical and forensic reasons. Imaging is often helpful, particularly because an accurate history is unusual. Furthermore, clinical examination and urine screens are often unreliable. Plain abdominal radiography and ultrasonography have been used with limited success. Thus, the use of alternative modalities, such as computed tomography (CT), is becoming more widespread. Although there have been no large trials, one false-negative has been reported. We report the case of a body packer whose CT appeared normal with standard abdominal windowing (level 40/width 400). However, on manipulation of the windowing (level −175/width 600), paraffin and heroin packages became conspicuous within the colon. We suggest that the simple step of reviewing images on wider than standard abdominal windows may be helpful in the detection of ingested illicit packages of fatty density within the bowel.     

Failure of surgical treatment in methamphetamine body-stuffers

Body stuffing is defined as ingestion of unpackaged or packaged illicit drugs in a quick process. The drugs have usually been wrapped loosely in cellophane, plastic bags, paper, or aluminum foil. Methamphetamine toxicity is a dangerous state that occurs during methamphetamine leakage from the ingested packages in the gastrointestinal tract. This is usually occurring with cocaine and heroin, but methamphetamine body stuffing may less commonly happen, as well. Accordingly, management of methamphetamine body-stuffers is an important subject that has remained a controversy in clinical and legal aspects.We have reported two body-stuffer cases who underwent exploratory laparotomy. Although surgery was done, it was not useful to exit packs and even led to severe methamphetamine toxicity.These cases show that surgical treatment may be ineffective and even harmful in body-stuffers. On the other hand, this report suggests that pre and post-operation abdominal CT-scan is necessary for evaluating surgical treatment in patients who are still symptomatic.     

Zur Aussagekraft von Nasenabstrichen bei Drogentoten betreffend der Applikationsart von Suchtstoffen

Nasal swabs were taken in 16-drug-related deaths (cotton wool buds) and 6 bodies exhibited fresh puncture marks indicative of intravenous drug application. In all these cases, only traces of opiates or cocaine or its metabolite at the most could be shown in the nasal swabs. In 10 cases no puncture marks were present. These nasal swabs contained relevant drug quantities as far as opiates and/or cocaine were involved. There was no evidence of diacetylmorphine (heroin) in any nasal swab, although monoacetylmorphine could be detected at a level mostly in the range of 30%–100% of the morphine concentrations. In the swabs with positive cocaine results there was evidence of markedly more cocaine than benzoylecgonine. The results of our investigation prove that examination of a nasal swab collected from deaths by drug intoxication can give good indications on the way the drug has been applied.     

Agony of the ecstasy: report of five cases of MDMA smuggling

The international smuggling of illicit drugs by the ingestion or rectal insertion of drug-filled packages is recognized in the trafficking of heroin and cocaine. Customs authorities, with suspicion of such activities, presented five subjects. The legally allowed radiological examination comprising one supine abdominal radiograph was performed. Radiographic findings demonstrated the presence of multiple enteric oval, capsule-shaped packages of soft tissue density. This was confirmed following supervised evacuation of bowel contents induced by the administration of laxatives. Analysis of the concealed material identified ecstasy (methylenedioxymethamphetamine (MDMA)), a substance not previously reported as transported by this route.     

Concentrations of Δ9-tetrahydrocannabinol,cocaine and 6-monoacetylmorphine in hair of drug abusers

Hair samples taken from 850 individuals with presumed drug abuse were tested simultaneously forΔ⁹tetrahydrocannabinol (THC), cocaine, heroin, the primary heroin metabolite 6-monoacetylmorphine (6-MAM) and morphine. The drugs were extracted with methanol under sonication. Compared to other extraction procedures this solvent extraction technique provides high extraction yields and less experimental effort. The analyses were carried out using gas chromatography - mass spectrometry (GCMS) in selected ion monitoring (SIM) mode. This procedure allows the simultaneous detection of amphetamine, methylenedioxyamphetamine (MDA), methylenedioxymetbamphetamine (MDMA) and methylenedioxyethylamphetamine (MDE). THC was found in 104 (12.2%), cocaine in 230 (27%) and 6-MAM in 141 (16.6%) samples. In addition to 6-MAM, morphine was detected in 87 (10.2%) and heroin in 38 samples (4.5%). The concentrations found were in a range 0.009-16.7 ng/mg for THC, 0.037-129.68 ng/mg for cocaine, 0.028-79.82 ng/mg for 6-MAM, 0.045-53.14 ng/mg for heroin and 0.011-7.800 ng/mg for morphine. The statistical distribution of the drug concentrations compared with the self-reported consumption behaviour of the users may possibly lead to a better understanding of the relationship between drug dosage and corresponding concentrations in hair.     

Radiological and practical aspects of body packing

Body packing represents the concealment of illegal substances in a person''s body with the aim of smuggling. “Body packers” either swallow drug-filled packets or introduce drug-filled packets into their bodies rectally or vaginally with the purpose of concealing them. The three main smuggled drugs are cocaine, heroin and cannabis products. Body packing represents a serious risk of acute narcotic toxicity from drug exposure, intestinal obstruction owing to pellet impaction and bowel perforation with consequent abdominal sepsis. A suspected body packer is generally admitted to hospital to perform imaging investigations and confirm the presence of drugs in his/her body. Radiological imaging methods are essential to diagnose body packing and to detect potential complications. Increasing sophistication of traffickers and improvements in packaging add to the detection difficulty. Radiologists should be aware of the appearance of drug packets in a range of imaging modalities. This article informs physicians about the challenging aspects of body packing, its background and medicolegal issues, what imaging methods can be used and what criteria are necessary to perform a correct diagnosis.Body packing was first reported in 1973 by Deitel and Syed,¹ who described a 21-year-old patient who had developed small bowel obstruction after swallowing a condom filled with hashish. The term “body packer” generally describes a drug courier who conceals packages containing illicit substances in the alimentary tract,^2,3 usually by swallowing them in order to carry them commonly across international borders. A wide range of illicit drugs may be transported in this way, including cocaine, heroin, marijuana, hashish, amphetamines and “ecstasy” (methylenedioxymethamphetamine).⁴ People included in these illegal practices refer to the emergency department with multiple diagnostic, ethical and legal issues. In addition to confirming the presence of concealed drugs, the radiologist must recognize and look for the signs of complications that these drug packages can cause. These include small bowel or large bowel obstruction, gastrointestinal perforation and subsequent acute peritonitis.⁵ In addition, package rupture can cause systemic drug absorption, resulting in drug toxicity or overdose.⁶ Radiologists have a key role in the identification of ingested packages.⁵ Plain abdominal radiography is currently used in the evaluation of patients with ingested, aspirated or introduced foreign bodies,^7–9 or for the identification of pneumoperitoneum in patients with alimentary tract perforation.¹⁰ It is also the most widely used radiological procedure to recognize drug-filled packets between 2 and 8 cm in length within the gastrointestinal tract of body packers.^5,11,12 Specific findings, such as the “double-condom” sign, can be indicative of drug packages but are not frequently identified on plain abdominal film.⁶ Recently, the use of CT in the evaluation of suspected body packers has become more widespread.⁴ However, there are legal restraints related to overexposure to radiation, and CT examinations are therefore generally performed in cases with negative abdominal plain films but a high index of suspicion of package concealment. The present review aims to highlight (1) salient identification criteria of a drug courier, (2) key findings in radiological imaging and (3) practical difficulties in the detection of the drug packets with different radiological investigations. Medicolegal issues related to body packing are also discussed.     

Death of a female addict due to heroin and cocaine overdoses: a case report with multiparameter evaluation

This study undertook a multiparameter evaluation of the death of a 21-year-old woman known to be an abuser of heroin and cocaine. The toxicological analysis of multiple postmortem specimens such as blood and hair was carried out using liquid chromatography atmospheric pressure chemical ionization tandem mass spectrometry (LC-APCI-MS-MS). The blood specimens of the deceased showed the presence of opium components such as morphine and its glucuronides together with cocaine and benzoylecgonine. The detected xenobiotic levels probably explained the cause of her death resulting from combined action of unintentional illicit drug overdose. By analysis of four 2-cm long hair segments, a heroin-cocaine addiction for at least 8 months antemortem was able to be documented; the presence of 6-monoacetylmorphine (6-MAM), cocaine, and benzoylecgonine was demonstrated. The histopathological findings of lesions of the internal organs of the deceased were consistent with long heroin and cocaine abuse. The use of multiple parameters, such as blood and hair segments as matrices and drug metabolites such as 6-MAM, morphine, glucuronides, and benzoylecgonine as target compounds, gave a well-defined outline of her death.     

Chasing "chasing the dragon" with MRI: leukoencephalopathy in drug abuse

Spongiform leukoencephalopathy is a rare complication from inhalation of heated heroin vapour, a practice called "chasing the dragon". The MRI findings are considered pathognomonic, making MRI important for diagnosis. This is especially true in busy urban emergency departments where a variety of patients may present obtunded, unable or unwilling to provide a useful history. Even though the MR pattern of "chasing" toxicity is considered pathognomonic, there are mimickers. We compare the MRI findings of two classic cases of chasing leukoencephalopathy with one case of mimickery from cocaine exposure only. All three cases had diffuse symmetrical white matter changes. MR spectroscopy (MRS) in chasing patients showed increased lactic acid and myo-inositol, decreased N-acetyl aspartate and creatine, normal to slightly decreased choline, and normal lipid peak. MRS in the cocaine exposure patient showed marked increase in lactic acid and lipids. MR perfusion in one chasing patient was normal. In conclusion: (1) All three cases have MR findings suggestive of spongiform leukoencephalopathy. MRS may help differentiate toxicity due to inhaled heroin from other non-heroin related toxicities. (2) Discordance between perfusion and spectroscopy in one chasing patient adds evidence that the disease is due to impaired energy metabolism at the cellular level. (3) MR findings of spongiform leukoencephalopathy secondary to chasing heroin can progress despite apparent abstinence of the drug and during clinical improvement, suggesting the MR changes may represent an evolving injury.     

Drug smuggling by body packing: what radiologists should know about it

Body packing is a distinct method for smuggling drugs. What radiologists need to know is discussed in this pictorial review. Radiologists are confronted with diagnostic imaging of body packers because of two main reasons: complications of body packing and identifying drug packets within the gastrointestinal tract. The standard examination used is plain X-ray of the abdomen in an upright and a supine position. Computed tomography is occasionally used but nevertheless described as a very accurate diagnostic tool. Ultrasound and MR imaging do not play an important role in that field. Depending on the purity of the drug, three different forms of attenuation have been described: hashish is denser than stool; cocaine appears similar to stool; and heroin has a gaseous transparence. The packets are of a round to oval form, usually of a particular uniformity and rarely confused with scybala if arranged like a pearl chain; therefore, plain X-ray is the method of choice to detect drug-filled packets within the gastrointestinal tract of body packers.     

Bilateral symmetrical basal ganglia infarction after intravenous use of cocaine and heroin.

A case is reported of a young man who developed bilateral symmetrical basal ganglia infarcts after intravenous use of cocaine and heroin. Ischemic infarcts of the brain are a known complication of to cocaine use, alone or in combination with heroin (speed balling). This symmetrical occurrence of infarction, however, is unusual and has not been reported after cocaine use.     

Drugs in blood samples from unconscious drug addicts after the intake of an overdose

This investigation includes whole blood samples from 53 drug addicts found unconscious in the Copenhagen area with evidence of a heroin overdose. Heroin/morphine was detected in 85% of the patients and other opioids in 11%. One or more benzodiazepines, most often diazepam, were detected in 75% of the patients. A blood alcohol concentration higher than 1.00 mg/g was detected in 57% of the patients. Methadone was detected in seven patients, ketobemidone in four, amphetamine in five and cocaine in one. This investigation showed widespread multi-drug abuse and heroin/morphine alone was detected in only one patient. As indicators of heroin intake, 6-monoacetylmorphine (MAM) and morphine were detected in this investigation.     

Investigation of illicit heroin seized in Malaysia: physical characteristics and chemical profiling

The high number of illicit heroin cases in Malaysia has led to the local forensic laboratory profiling of the physical and chemical characteristics of 311 street samples submitted as heroin cases in 2010. Visual examination and physical characteristics of the heroin substance and plastic packages are described. The preferred ranges of the weight of substances per package and the dimensions of the plastic package/receptacle are defined. Analysis of eight major components (three adulterants and five opium alkaloids) is also detailed. It was found that most samples contained less than 10% heroin base and more than 80% caffeine. Physical and chemical data together provide a quick overview of the samples seized within the country. Principal component analysis of the five major opium alkaloids present in the seized samples suggested that there were at least two sources responsible for the samples analyzed.     

Patterns of illicit drug use of prisoners in police custody in London, UK

AIMS AND METHODS: The aims of the study were to explore the current characteristics of drug misusers seen in police custody and identify trends or changes that have taken place in the last decade. A prospective, anonymised, structured questionnaire survey was undertaken of consenting consecutive, self-admitted illicit drug users seen by forensic physicians in police custody within the Metropolitan Police Service in London, UK in 2003. RESULTS: 30% of detainees were dependent on heroin or crack cocaine. Drug users (n=113) were studied in 2003. 95.4% completed the questionnaire. 82% were male, 18% female. Mean age was 28.5 y (range 18-49). 80% were unemployed; significant mental health issues (e.g., schizophrenia) were present in 18%; 15% had alcohol dependence; heroin was the most frequently used drug (93%); crack cocaine -- 87%; mean daily cost of drugs -- heroin GBP 76 (range 20-240), crack GBP 81 (range 20-300). >50% users inject crack and heroin simultaneously. 56% used the intravenous route; 25% had shared needles; 100% had accessible sources of clean needles; 6.4% were hepatitis B positive; 42% were aware of hepatitis prophylaxis; hepatitis C positive -- 20.2%; 3.6% were HIV positive. Mean length of time of drug use was 7.5 y (range 1 month -- 20 years); 82% had served a previous prison sentence; 54% had used drugs in prison; 11% had used needles in prison; 3% of users stated they had started using in prison. 38% had been on rehabilitation programs; 11% had been on Drug Treatment and Testing; Orders (DTTO); 32% had used the services of Drug Arrest Referral Teams in police stations; 10% were in contact with Drug Teams at the time of assessment. CONCLUSIONS: In the last decade, there appears to be a substantial increase in the prevalence of drug use in this population -- particularly of crack cocaine. Treatment interventions are either not readily available, or not followed through. In very general terms, the illicit drug use problem appears to have significantly worsened in the population seen in police custody in London, UK, in the last decade although there is evidence that health education and harm reduction messages appear to have had some positive effects.     

Underlying causes of cocaine, amphetamine and opioid related deaths in Australia

OBJECTIVE: To examine the characteristics of deaths in Australia where opioids, cocaine or amphetamines were mentioned, taking into account changes in the use and availability of these drugs in recent years. DESIGN: Data were analysed from the Australian Bureau of Statistics and Causes of Death dataset between 1997 and 2002 on all deaths in which cocaine, amphetamines or opioids were mentioned including deaths where (a) the drugs were considered an underlying cause of death, (b) the drugs contributed to accidental drug-induced death, and (c) deaths primarily due to other causes. Data from the Australian National Drug Strategy Household Survey were also used to examine the prevalence of use of amphetamines, cocaine and opioids in Australia. RESULTS: Thirteen deaths were attributed primarily to cocaine, 68 to amphetamines, and 4591 to opioids. An increase occurred in mentions of amphetamines, but half of these were primarily attributed to opioids. Opioid related deaths declined dramatically in 2001, consistent with a marked reduction in availability of heroin in Australia. Cocaine mentions remained relatively stable, with most cases primarily attributed to opioids. Of the other underlying causes of death, suicide was the most prevalent underlying factor, particularly for amphetamine and opioid related deaths. CONCLUSIONS: Compared with opioid-related deaths, there are small numbers of deaths related to psychostimulants in Australia. Accidental drug induced deaths account for the majority of deaths in which these drugs are mentioned, although minorities of drug related deaths are attributed to suicide.     

Body packing presenting as sudden collapse.

Cocaine is one of the most rapidly growing drugs of abuse and with it comes an ever-increasing sophistication in concealment from Customs and Police, and may even result in clinicians failing to detect the concealment of packages within the intestinal tract or other body orifices. We present one such case where death arose from rupture of a package of cocaine within the rectum.     

Zur toxikologischen Bewertung der Lokalanästhetika Lidocain und Tetracain bei Drogentodesfällen

In recent years an increasing number of drug fatalities with blood concentrations of lidocaine up to 33 μg/ ml or of the tetracaine metabolite 4-n-butylaminobenzoic acid up to 8.6 μg/ml was observed in Berlin. These high concentrations originated from the use of the local anaesthetics as adulterants in cocaine, heroin or cocaine-heroin mixtures. The comparison of the lidocaine concentrations with that of 38 fatalities with a different cause of death, in which the drug was used as an antiarrhythmic during resuscitation attempts (0.1–24 μg/ml) and with literature data on local anaesthesia accidents leads to the conclusion that in a substantial number of drug cases an intoxication by the local anaesthetics alone or in combination with other drugs is sufficient to death. In seven cases the concentration of 4-n-butylaminobenzoic acid was above 4 μg/ml (corresponding to > 5.5 μg/ml tetracaine). These values confirm the stronger toxicity of tetracaine in comparison to lidocaine known from the literature. As a reason for the particularly high danger of the use of local anaesthetics as adulterants in illicit drug mixtures, it must be assumed that after application of normal amounts by intravenous bolus injection, very high blood concentrations appear immediately in the heart and CNS, which cause death by central paralysis and blockade of the cardiac conduction system.