Clinical update

How to manage patients who may be concealing drugs internally

The Royal College of Emergency Medicine has published a best practice guideline on managing cases of suspected internal drug trafficking

The Royal College of Emergency Medicine has published a best practice guideline on managing cases of suspected internal drug trafficking

Essential information

Most forms of illegal drugs originate overseas and are trafficked into the UK via various routes, says the National Crime Agency (NCA) , including in vehicles from continental Europe and by airline passengers.

Trafficking methods frequently rely on the recruitment of vulnerable people as mules often at great risk to their lives and welfare, says the NCA.

People may conceal drugs by swallowing packages or placing them in their anus or vagina.

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The Royal College of Emergency Medicine has published a best practice guideline on managing cases of suspected internal drug trafficking

A policewoman by the side of a patient's bed. The Royal College of Emergency Medicine has published a best practice guideline on managing cases of suspected internal drug trafficking
Picture: Neil O’Connor

Essential information

Most forms of illegal drugs originate overseas and are trafficked into the UK via various routes, says the National Crime Agency (NCA), including in vehicles from continental Europe and by airline passengers.

Trafficking methods frequently rely on the recruitment of vulnerable people as mules – often at great risk to their lives and welfare, says the NCA.

People may conceal drugs by swallowing packages or placing them in their anus or vagina.

What’s new?

In September, the Royal College of Emergency Medicine (RCEM) published a best practice guideline on managing suspected internal drug traffickers (SIDTs).

The guideline includes definitions of the various ways people conceal illicit drugs; recommendations for clinical management, depending on how drugs are being concealed; legal and ethical issues; and discharge advice.

Key recommendations

A low dose CT scan of the abdomen and pelvis is the investigation of choice for SIDTs, says the RCEM.

Intimate searches are not recommended, even with the aid of a speculum or proctoscope as they may result in injury to the patient or examiner. There is a risk of breaking the packages and the search may not reveal any that are deeply located.

‘Body stuffers’ and ‘pushers’ should be observed for eight hours after ingestion if asymptomatic or longer if symptomatic, the college advises.

Body stuffers conceal drugs wrapped in cling film in their mouth, which may be swallowed to avoid detection.

These packages are poorly protected in the digestive system, so they are more likely to lead to toxic symptoms, with a delayed effect of the release of the drugs.

Pushers conceal drugs in their vagina or rectum.

Indications for the urgent surgical removal of packages include: abdominal pain; radiological evidence of remaining packages which are too large to pass through the gastrointestinal tract; and evidence of significant or worsening toxicity, such as acute psychosis or adrenergic symptoms.

How you can help your patient

While SIDTs remain under arrest, with police officers maintaining a close watch to prevent swallowing or disposal of any evidence, they still have the right to speak confidentially to a healthcare professional.

If the police are asked to leave, suitable arrangements, such as the presence of hospital security, should be made.

While the police can authorise and request an intimate search, emergency physicians cannot be compelled to undertake it, even if the patient consents.

The police also have the authority to transfer detainees to a hospital for an X-ray or ultrasound but clinicians are not required to request either.

In all cases, clinicians should assess the need for imaging themselves and patients have the right to refuse investigations.

However, patients should be advised that if they are carrying drug packages internally, there is a significant risk to their health if they burst or leak.

Expert comment

Linsey Sheerin, service manager for urgent and emergency care and police custody, Belfast Health and Social Care Trust

Linsey Sheerin, service manager for urgent and emergency care and police custody, Belfast Health and Social Care TrustIt’s good to see the RCEM, the Faculty of Forensic and Legal Medicine, the National Police Chiefs’ Council and the Royal College of Radiologists come together to develop this guidance.

I am pleased that it includes information about the common toxidromes, including what to look out for with cocaine and heroin, and how to manage these patients.

People can deteriorate quickly and picking up on subtle signs is key to good clinical management.

Nurses are there to care for patients when they need it, whatever their personal story. If you work near an airport, managing SIDTs won’t be uncommon, but this guidance is also applicable to all nurses working in any emergency department (ED), as someone may swallow a drug package because they think the police are about to arrest them.

It’s essential that there is clear communication, guidance and support for people working in EDs to manage patients who may be concealing drugs internally.

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