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Key findings

  • Drug smuggling is an increasingly prevalent problem, and officials at border control or airports may ask radiologists to examine suspected drug "mules" who conceal drugs in their body
  • The two principal methods of concealment are body packing (swallowing large volumes of drugs to hide them in the gastrointestinal tract) and body pushing (placing drug packages or paraphernalia in the rectum or vagina)
  • Abdominal radiography remains the most widespread initial imaging technique for identification of drug packages; however, false-negative and false-positive diagnoses are possible due to improved smuggling methods
  • Low-dose CT is typically used in the U.S. for cross-check of the diagnosis and to rule out complications such as perforation or bowel obstruction

Trafficking of illicit drugs has grown exponentially over the past decade. Cocaine, heroin, methamphetamine and hashish are the substances most often concealed by "mules," who transport illicit drugs by swallowing them or concealing them in a body cavity.

When suspected drug mules are apprehended at border control or an international airport, they are taken to hospital emergency departments for imaging. Rhea Malhotra, MD, cardiologist and researcher in the Cardiovascular Research Center at Massachusetts General Hospital, and Ajay Singh, MD, of the Department of Radiology at Mass General, review in Emergency Radiology how to detect drug packages to protect smugglers from complications, including overdose, and prevent the release of contraband into the community.

Internal Smuggling Techniques

The two principal methods of concealing drugs in the body are:

  • Body packing—Swallowing large volumes of drugs (in a balloon, condom, etc.) to hide them in the lumen of the gastrointestinal tract. This method presents the greatest risk of complications

  • Body pushing—Placing drug packages or paraphernalia in the rectum or vagina. Detection by radiography is more difficult in these cases

Body stuffing is a variation of body pushing in which small amounts of loosely wrapped drugs are transported, sometimes in the mouth for a short time or upon encountering law enforcement.

The same individual may use more than one method.

Evading Detection

Body packers may attempt to decrease the radiodensity difference between drug packages and surrounding stool by:

  • Wrapping drugs in aluminum foil, plastic food wrap or carbon paper
  • Loosely wrapping narcotics to incorporate air
  • Inducing constipation with loperamide and diphenoxylate
  • Smuggling liquid forms of narcotics, which also have the advantage of more easily taking the shape of the intestinal lumen

Additionally, drug mules may attempt to disrupt clear imaging by moving in the scanner, breathing rapidly or feigning agitation.

Radiography

In some countries, informed consent for imaging is mandatory, while others allow radiologic tests by request of customs officers or other security personnel. The radiologist must always report to the ordering physician, not directly to law enforcement.

Abdominal radiography in supine projection is the standard test for detecting drug packages because of its wide availability, low radiation dose, low cost, relatively fast speed and high sensitivity (85%–90%). Still, false-negative and false-positive diagnoses are possible due to improved smuggling methods.

Confirmatory Imaging

If radiographic findings are suspicious, other imaging is necessary as a cross-check and to rule out complications, especially perforation or bowel obstruction. Low-dose CT is an efficient, accurate method of locating packages concealed in any way. The practical limitation in the U.S. and some other countries is the need for informed consent due to the higher radiation dose.

For children, pregnant individuals and other complex cases, ultrasonography or MRI may be appropriate, although MRI has limited value for imaging body packers because of artifacts due to bowel peristalsis.

The review discusses in detail, with sample images, the radiologic signs of various methods of drug concealment based on parameters such as packet shape, radiolucency and air pockets.

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