Substance Abuse In contrast, body ‘stuffers’ are those who swallow a small
SUBSTANCE ABUSE
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 stuffers.
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.16,17 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).18 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.19 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.15 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.20 Liquid paraffin should not be used because it can
MEDICINE 40:2 48 Africa Health 76
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.
A
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2011 Published by Elsevier Ltd. July 2012
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