A five-year review of the medical outcome of heroin body stuffers

Clinical, Diagnostic, and Treatment Features of Body Packing in Brazil: Drugs, Cell Phones, and Beyond

INTRODUCTION

Body packing consists of the concealment of substances (drugs and non-narcotics) or products inside the human body with the purpose of smuggling and may represent an emergency due to the fatal risk of narcotic toxicity, intestinal obstruction, and visceral perforation. However, non-narcotic body packing, especially in developing countries, is under-evaluated. Thus, the objective of this study was to evaluate cases of body packers in Brazil as regards narcotic and non-narcotic contents.

METHODS

This retrospective study analyzes the medical records of body packers admitted from January 2015 to December 2019 at one of the main tertiary hospitals in central Brazil.

RESULTS

Ten cases of body packing were observed. We found that five patients carried drugs, while seven carried non-narcotic substances such as cell phones and accessories. All the patients were male, prisoners, and young adults. In six patients, there was gastrointestinal obstruction, and in three, there was acute narcotic intoxication. Abdominal radiography diagnosed eight of the cases. In nine of the cases, emergency laparotomy was required, but all patients successfully recovered.

CONCLUSION

There was a higher prevalence of body packing of non-narcotic content; however, diagnostic and surgical approaches were similar to those of narcotic content. Clinicians must be aware of both non-narcotic and narcotic body packing.

Endoscopic Management of Ingested Narcotic Substances: A Case Report and Literature Review

Management of swallowed narcotics remains in contention despite the increased frequency of occurrence. International societies recommend conservative therapy with escalation to surgical interventions in cases where drug packets do not progress. However, multiple studies demonstrate a treatment benefit of endoscopic intervention. We report the case of a 27-year-old male who presented after ingesting heroin bundles and failed the 48-hour of conservative therapy. Repeat computed tomography scanning demonstrated no movement of the package. Endoscopic retrieval was successful, and the patient was discharged the same day. Endoscopic intervention in the removal of bagged narcotics should be considered in patients presenting after purposely ingesting narcotics as means of planned concealment. 

Complications and hospital stay after endoscopic retrieval of drug baggies in body stuffers: an observational prospective study

Body stuffers routinely receive conservative treatment, i.e. administration of the laxative polyethylene glycol for the passage of ingested drug baggies and observation. Endoscopic baggie removal may offer a safe alternative that could result in shorter hospitalization. We aimed to compare complications, hospital stay, and final outcome in body stuffers assigned to endoscopy versus conservative treatment. This is an observational prospective study of body stuffers presenting to a clinical toxicology center in Tehran (Iran) in 2016-2019, irrespective of the drug ingested. Eligible patients had baggies in their upper gastrointestinal tract and presented without severe poisoning. Patients received either endoscopy or conservative treatment, and clinical outcomes were compared between the groups. A total of 69 patients were enrolled, with a median age of 29 years (range 18-64), among whom 1 was female (2%). Eighteen and 51 patients were endoscopically and conservatively managed, respectively. Drugs most commonly ingested were heroin in endoscopy patients (8/18 cases; 44%) and methamphetamine in the conservative group (28/51 cases; 55%). Endoscopy patients had a shorter hospital stay (median 1.5 vs. 2 days, P = 0.018). In the conservative group, one patient died, and the rate of complications was significantly higher, with more patients experiencing side effects (OR = 1.4, 95% CI = 1.2, 1.7) and requiring intubation (OR = 1.3, 95% CI = 1.1, 1.5). Endoscopic retrieval was associated with fewer complications and shorter hospitalization. Endoscopy may be a safe treatment for body stuffers without severe poisoning on presentation.

Polyethylene glycol electrolyte lavage solution increases tablet dissolution of acetaminophen in an in vitro model mimicking acute poisoning

INTRODUCTION

Polyethylene glycol electrolyte lavage solution (PEG-ELS) is similar to pharmaceutical solvent propylene glycol and used following acute poisonings for whole bowel irrigation (e.g., "body stuffing"). This raises concern of PEG-ELS increasing solubility following acute ingestions of non-sustained release xenobiotics in the stomach. We theorized PEG-ELS increases solubility of acetaminophen in an in vitro stomach model.

MATERIAL AND METHODS

An in vitro artificial stomach with 500 mL simulated gastric fluid and either 500 mL of sodium chloride 0.9% (group A) or 500 mL of PEG-ELS (group B). Ten non-sustained release acetaminophen tablets added with concentrations 0, 15, 45 and 90 min in triplicate. Mean concentrations and mean area under the curve (AUC) (mg-min/L to 90 min).

RESULTS

In control group A (normal saline + simulated gastric fluid) mean acetaminophen concentrations 0, 3, 13 and 36 mg/L at 0, 15, 45 and 90 min, respectively. In group B (PEG-ELS + simulated gastric fluid) mean acetaminophen concentrations 0, 34, 109 and 136 mg/L at 0, 15, 45 and 90 min, respectively (p < 0.05). Mean AUC 0-90 1385 [95% C.I. 990.5-1779] mg-min/L in control group A compared to mean AUC 0-90 in group B (PEG-ELS) 7673 mg-min/L [95% C.I. 4832-10513] (p < 0.05).

DISCUSSION

Group B (PEG-ELS) with significantly higher mean acetaminophen concentrations and greater mean AUC compared to control group A (normal saline).

CONCLUSION

We demonstrated increased mean acetaminophen concentrations and increased mean AUC of following exposure of PEG-ELS in an artificial stomach model.

A Curious Case of the Persistent Body Stuffer

A 29-year-old male presented to our emergency department with complaint of abdominal pain after allegedly ingesting a 4-gram packet of heroin in an attempt to evade detection. Initial evaluation including computed tomography (CT) of the abdomen/pelvis with intravenous and oral contrast, as well as laboratory workup was negative and the patient was discharged. The patient returned 3 days later with complaint of "I feel high" and severe constipation, and demonstrated an opiate toxidrome requiring naloxone with improvement of symptoms. A repeat CT of the abdomen/pelvis, this time without contrast revealed a 2.1 × 1.8 cm foreign body in the gastric antrum. The patient was promptly taken to endoscopy with surgical backup. Foreign body removal included multiple plastic bags encasing heroin, which had sustained a small leak causing a gastric outlet obstruction as well as a slow opiate toxidrome. The foreign body was removed and the patient was observed and discharged with a favorable outcome.

Management recommendations for body stuffers at emergency units

Managing body packers and stuffers is a challenge to emergency physicians, stuffers in particular, as there is no systematic approach to their treatment. The aim of this study was therefore to review all available literature on body stuffing and propose a guide to manage these patients. We searched Medline/PubMed, Google Scholar, and Scopus for published work on body stuffers using key words "body stuffer", "body stuffing", "poisoning", "toxicity", and "treatment" without a time limit and retrieved 290 articles, of which 61 remained after exclusion of those on "body packers" and repetitive documents. This review article evaluates and summarises the information gathered from them. The main step in body stuffer management is observation to make sure that they have passed all the swallowed packages of drugs of abuse. In some cases, imaging can be quite useful. Diagnostic pitfalls may be avoided with abdominopelvic CT without contrast, which is probably the best diagnostic method to determine the presence and the number of packages in these patients. Treatment should be specific for each group of drugs, whether it is opioids, cocaine, or amphetamine. Surgical interventions are indicated for obstruction of the intestines or package rupture. Legal precautions should be taken because of the legal complexity of body stuffing cases.

Correlation of abdominopelvic computed tomography with clinical manifestations in methamphetamine body stuffers

Little is known about methamphetamine body stuffers and correlation of clinical manifestations with imaging studies. Current study was done to determine abdominopelvic computed tomography findings and clinical manifestations in methamphetamine body stuffers. In an IRB-approved routine data base study, demographic characteristics, clinical findings, and CT results of 70 methamphetamine body stuffers were retrieved. According to the clinical manifestations, the patients were categorized into either benign- or severe-outcome group. Also, they were determined to have positive or negative CT results. In the group with positive results, number and place of the baggies were determined, as well. Results of the CT were compared between the two groups. Almost 43% of the patients had positive abdominopelvic CT results. Mean density of the packs was 176.2 ± 152.7 Hounsfield unit. Based on the clinical grounds, 57% of the patients were in the benign- and 33% were in the severe-outcome group. In the benign group, 45% of the patients had positive CTs while in the severe-risk group, this was 40% (p > 0.05). Except variables defined as severe outcome (seizure, intubation, creatinine level, aspartate aminotransferase level, creatine phosphokinase and troponin level), agitation, on-arrival pulse rate, lactate dehydrogenase, bicarbonate, base excess, loss of consciousness and hospitalization period were correlating factors. But in regression analysis, we could not find a significant variable that prognosticate severe outcome. It seems that there is no relationship between the CT findings and clinical manifestations of the methamphetamine body stuffers. Severe outcomes may be observed even in the face of negative CTs.

Management of body stuffers presenting to the emergency department

OBJECTIVE

The aim of this study was to establish a management protocol for body stuffers presenting to the emergency department.

METHODS

This is a retrospective observational case series of patients presenting to the emergency department of a large inner-city hospital as 'body stuffers' during the period between 1 January 2006 and 31 October 2011, irrespective of the type of drug ingested. We reviewed demographic data, ingestion characteristics, clinical progress and outcome.

RESULTS

A total of 126 patients were included in the study, with a mean age of 31±8.10 years (range 15-58 years), among whom 106 were male (84%). Drugs ingested were as follows: heroin (n=61, 48%), cocaine (n=58, 46%), other drugs (n=20, 16%) and unknown (n=10, 8%). Of the patients, 23 (18%) ingested more than one drug. At presentation, 96 had features of drug toxicity. The presence of depressant drug toxidrome was more commonly observed among heroin users, but stimulant drug toxidromes were seen across all groups. Of the patients, 12 developed changes in clinical state, with a mean time to development of symptoms of 2 h 50 min±1 h 39 min (range from 1 h 0 min to 5 h 36 min). Abdominal radiography showed the presence of foreign bodies in 8% of the tests performed, and packets were recovered from one patient who underwent gut decontamination.

CONCLUSION

Patients developed new or worsening features of drug toxicity within 6 h of presentation. Toxidromes observed are often not drug/class specific, and treatment including gut decontamination and radiography do not aid in expediting discharge. We propose an observation period of 6 h from the time of admission as the time required if the patient is asymptomatic or there is resolution of presenting signs and symptoms.

The role of radiology in diagnosis and management of drug mules: an update with new challenges and new diagnostic tools

Emergency physicians and radiologists have been increasingly encountering internal concealment of illegal drugs. The packages commonly contain powdered solid drugs such as cocaine, heroin, methamphetamine and hashish, but they may also contain cocaine in the liquid form. The second type of package has recently been more commonly encountered, and poses a greater diagnostic challenge. As clinical evaluation and laboratory tests frequently fail to make the correct diagnosis, imaging examination is typically required. Imaging methods assume a vital role in the diagnosis, follow-up and management. Abdominal X-ray, ultrasonography, CT and MRI are used for the imaging purposes. Among the aforementioned methods, low-dose CT is state-of-the-art in these cases. It is of paramount importance that radiologists have a full knowledge of the imaging characteristics of these packages and accurately guide physicians and security officials.

Heroin activates ATF3 and CytC via c-Jun N-terminal kinase pathways to mediate neuronal apoptosis

Background

Drug abuse and addiction has become a major public health problem that impacts all societies. The use of heroin may cause spongiform leukoencephalopathy (SLE).

Material/Methods

Cerebellar granule cells were derived from 7-day-old Sprague-Dawley rat pups.

Neurons were dissociated from freshly dissected cerebella by mechanical disruption in the presence of 0.125% trypsin and DNaseI and then seeded at a density of 4×10⁶ cells/ml in Dulbecco’s modified Eagle’s medium/nutrient mixture F-12 ham’s containing 10% fetal bovine serum and Arc-C(sigma) at concentrations to inhibit glial cell growth inoculated into 6-well plates and a small dish.

Results

We found that heroin induces the apoptosis of primary cultured cerebellar granule cells (CGCS) and that the c-Jun N-terminal kinase (JNK) pathway was activated under heroin treatment and stimulated obvious increases in the levels of C-jun, Cytc, and ATF3mRNA. CYTC and ATF3 were identified as candidate targets of the JNK/c-Jun pathway in this process because the specificity inhibitors SP600125 of JNK/C-jun pathways reduced the levels of C-jun, Cytc, and ATF3mRNA. The results suggested that SP600125 of JNK/C-jun can inhibit heroin-induced apoptosis of neurons.

Conclusions

The present study analyzes our understanding of the critical role of the JNK pathway in the process of neuronal apoptosis induced by heroin, and suggests a new and effective strategy to treat SLE.

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.

Heroin activates Bim via c-Jun N-terminal kinase/c-Jun pathway to mediate neuronal apoptosis

Heroin is reported to cause spongiform leukoencephalopathy (SLE) in heroin addicts and the exact mechanism has not yet been identified. In the present study, we found that heroin could induce apoptosis of primary cultured cerebellar granule cells (CGCs) and Bim was upregulated both transcriptionally and post transcriptionally during CGCs apoptosis. Upregulated Bim translocated to mitochondria and Bax was activated under heroin treatment. Genetic knockdown of Bim using lentiviruses significantly prevented neuronal apoptosis induced by heroin. Meanwhile, c-Jun N-terminal kinase (JNK)/c-Jun pathway was activated in heroin-induced apoptosis. Bim was demonstrated as a downstream target of JNK/c-Jun pathway in this process because pharmacological inhibition of JNK reduced the levels of Bim mRNA and protein. These results indicate that Bim plays a critical role in the neurotoxic process by heroin and JNK/c-Jun pathway acts upstream of Bim in regulating heroin-induced neuronal death. This represents a detailed mechanism of heroin-induced neuronal apoptosis and may provide a new and effective strategy to treat heroin-induced addiction and SLE.