Heroin

Accepted Manuscript Drug-related deaths with evidences of body packing: two case reports and medico-legal issues Simone Cappelletti, Mariarosaria Aromatario, Edoardo Bottoni, Paola Antonella Fiore, Guido Maria De Mari, Costantino Ciallella PII: DOI: Reference:

S1344-6223(16)30022-0 http://dx.doi.org/10.1016/j.legalmed.2016.03.007 LEGMED 1308

To appear in:

Legal Medicine

Received Date: Revised Date: Accepted Date:

24 December 2015 29 February 2016 13 March 2016

Please cite this article as: Cappelletti, S., Aromatario, M., Bottoni, E., Fiore, P.A., De Mari, G.M., Ciallella, C., Drug-related deaths with evidences of body packing: two case reports and medico-legal issues, Legal Medicine (2016), doi: http://dx.doi.org/10.1016/j.legalmed.2016.03.007

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Drug-related deaths with evidences of body packing: two case reports and medico-legal issues Simone Cappelletti1*, Mariarosaria Aromatario 1, Edoardo Bottoni1, Paola Antonella Fiore1, Guido Maria De Mari1, Costantino Ciallella1

Authors’ Affiliations: 1

Legal Medicine Section – SAIMLAL Department, SAPIENZA University of Rome, Viale Regina

Elena, 336, 00161 Roma, Italy

* Corresponding author: Simone Cappelletti, MD Phone: 00390649912618 Fax: 0039064455335 e-mail: simone.cappelletti@uniroma1.it Viale Regina Elena, 336 – 00161 Rome, Italy

The authors report no conflicts of interest

Drug-related deaths with evidence of body packing: two case reports and medico-legal issues 1.

Introduction

Body packing is a general term used to indicate the internal transportation of drug packages within the gastrointestinal tract; the most common drugs involved are cocaine and heroin [1]. It is noteworthy that these drugs may be frequently and deliberately adulterated with various cutting agents such as piracetam and levamisole, respectively in the heroin and cocaine body packer cases presented in the paper.

The drugs concealed are wrapped in the form of capsules, made by cellophane, layers of latex, condoms, plastic bags, rubber cots, plastic foil, aluminum foil, wax, carbon paper or self adhesive tape [2,3]. Body packers usually carry about one kg of drug, divided into 50 - 100 packets of 8 - 10 g each, although drug smugglers carrying up to 500 packets have been reported [4-6].

Despite the increase in quality of the packaging procedures, and the consequent decrease in mortality among body packers, the rupture of the packets and the consequent toxicity remain the most important life-threatening complications [7]. Nevertheless, packet failure may still cause poisoning in the country of origin, during the journey, or at their destination, as in the cases presented. However, clinicians and forensic pathologists sometimes may discover the concealed drug packages through medical examination or autopsy of cases with an unknown cause of death [8,9].

The aim of this paper is to describe the forensic examination and the toxicological analysis carried out on both drug packages and biological samples, as well as to highlight the main medico-legal issues that commonly arise in cases of suspected or ascertained body packers.

2.

Case reports

2.1. Case 1 An adult male with false ID card coming from a country of Western Europe by cruise ship was found dead in his cabin at the Rome harbor. The man was 173 cm in height and 90 kg in weight. The examination of clothes and personal effects, carried out by police officers, didn’t shown any important elements. The external examination did not reveal any evidence of trauma.

A supine plain X-ray of the chest and abdomen was carried out. No pneumothorax, rib fractures or other significant elements were noted. There were multiple suspicious oval shaped radio-opacities projected over the stomach and through the gastrointestinal tract that were identified as drug packages (Figure 1).

Figure 1 about here

The autopsy examination showed marked congestion of cerebral vessels, with no evidence of intracranial hemorrhage.

The brain weighted 1370 g and its coronal and transverse sections were unremarkable. The heart weighted 310 g, no atheroma was seen in the coronary arteries. The lungs (left 460 g, right 480 g) were congested and edematous,

mediastinal and airway structures were unremarkable. The liver (1075 g) shown steatosis and congestion of the parenchyma. The kidneys (left 148 g, right 165 g) shown marked congestion.

During the autopsy, one package was identified in the esophagus, 22 in the stomach (a single package was blocking the pylorus), 2 in the duodenum and 44 in the colon and rectum; a total of 69 packages were collected. The stomach was grossly distended and contained moderate amount of whitish-yellow paste like material that was collected for further toxicological analysis. The gastric mucosa was markedly congested with no signs of ulceration.

Specimens of the brain, skin, heart, lungs and liver, collected for further histological analysis, did not reveal any significant elements. Samples of peripheral blood, urine, bile and gastric content were collected and stored at -20 °C for toxicological examination.

2.1.1. Toxicological findings Blood and urine screening for drug abuse (Triage® Drugs of Abuse Plus TCA Panel, Alere, USA) revealed an assumption of opiates. Samples of peripheral blood, urine, liver, bile, gastric contents and drug packages were taken for further analysis performed using validated gas chromatography–mass spectrometry (GC/MS) procedures [10,11].

Quantitative analysis, reported in Table 1, showed the presence of morphine in peripheral blood, urine, bile, and gastric content as well as its metabolite 6-MAM in bile and gastric content. No alcohol and other conventional drugs or poisons were detected in the samples. Traces amounts of piracetam, as cutting agent, has been also detected.

2.2. Case 2 An adult white male coming from North Africa by airplane was found dead in the bathroom of a hotel room in Rome.

The body was that of an adult male, 180 cm in height and 70 kg in weight. Clothes and personal effects were seized by police officers and didn’t shown any important elements. The external examination did not reveal any evidence of trauma.

In the bathroom trash can numerous wax fragments have been found; moreover, some laxatives have also been found.

The autopsy examination showed the following. The lungs (right 600 g, left 625 g) were congested and edematous, mediastinal and airway structures were unremarkable. No remarkable signs were noted at the expense of heart, liver and kidneys.

Important findings were seen in alimentary tract where 10 packages were located in the stomach, two in the duodenum and four in the colon and rectum; a total of 16 packages were collected. The stomach was distended and contained moderate amount of whitish-yellow paste like material and food that were collected for further toxicological analysis.

The gastric mucosa was markedly congested with no ulcerations.

Specimens of the brain, heart, skin, lungs and liver, collected for further histological analysis, did not reveal any significant elements. Samples of peripheral blood, urine, bile and gastric content were collected and stored at -20 °C for toxicological analysis.

2.2.1. Toxicological findings

Blood and urine screening for drug abuse (TriageÂŽ Drugs of Abuse Plus TCA Panel, Alere, USA) resulted positive for cocaine and benzodiazepine. Samples of peripheral blood, urine, bile, gastric content and drug packages were collected for further analysis performed using validated GC/MS procedures [11,12]; positive qualitative and quantitative results for cocaine, benzoylecgonine and levamisole were obtained. Benzodiazepine and tetrahydrocannabinolic acid (THCA a biosynthetic precursor of tetrahydrocannabinol) were detected as well; results are shown in Table 1.

Table 1 about here

2.3. Forensic examination of the drug packages

2.3.1. Case 1

Packages were of variable weight, each between 8.7 and 12.4 g, of variable length, each between 60 and 70 mm and of variable width, each one between 18 and 22 mm. Only one package was smaller than others, 32 mm in length and 12 mm in width. The total weight of all sixty-nine packages was 764 g. Toxicological analysis carried out on the heroin drug packages permitted us to detect trace amounts of piracetam as adulterating substance.

The external examination showed cylindrical shaped packages, undamaged, wrapped with a condom and two layers of plastic film. The content in packages was white crystal-like powders (Figure 2a).

2.3.2. Case 2 The sixteen packages analyzed were of variable weight, each between 9.2 and 12.6 g, of variable length, between 63 and 75 mm and of variable width (between 16 and 21 mm). The total weight of all sixteen packages was 149 g.

The external examination showed cylindrical shaped packages, some damaged. From outside to inside, the layers of each package was composed of red wax, cellophane and, finally, latex. The content in packages was white powders (Figure 2b). The analysis conducted on the packages revealed that all sixteen samples contained 87.3 % cocaine hydrochloride, diluted with levamisole (3.3 %), The wax fragments, found in the bathroom trash can, were empty and the we could not reconstruct the exact number of these further drug packages.

Figure 2 about here

3.

Discussion

In both cases the cause of death was due to acute drug intoxication. According to Meissner et al. [13], morphine blood levels in victims of lethal heroin intoxication vary from 0.03 to 5 mg/L; in body packers, because of the possibility of a package failure, these values may be higher. The blood morphine values obtained in the first case (0.8 mg/L) led us to confirm that the death was due to acute heroin intoxication. Furthermore, the absence of damaged packages and the presence of trace amounts of piracetam in both fluids and packages, permitted us to hypothesize that the morphine

levels might be related to a leaking and/or diffusion of the drug through the package plastic film membranes; the latter is a frequent eventuality, especially when the quality of packaging is extremely poor.

The toxicological analysis showed the presence of piracetam as adulterant. This substance is a member of the class of prescription drugs known as nootropics which improves behavior, cognitive and memory functions. Its use as a heroin adulterant has been reported in literature for a brief period [14]. In the case presented, the presence of piracetam, because of its low values, has not been considered significant in the mechanism of death. Up to know, even though its use as adulterating substance has becoming more frequent in some drug markets [14], this represent the first case of a body packer concealing a heroin-piracetam mixture.

In our second case the high blood cocaine values (4.4 mg/L) permitted us to confirm that the death was due to acute cocaine intoxication; the high cocaine and its metabolites values encountered in this case are related to the rupture of the drug packages. The toxicological analysis also showed the presence of levamisole as adulterant. Levamisole is a pharmaceutical with anthelminthic and immunological properties that was previously used in both humans and animals to treat inflammatory conditions and cancer. Its use as a cocaine adulterant has been reported in the United States and Europe since 2004 [15]. In the case presented the values of levamisole have been considered not significant in the mechanisms of death. Nevertheless, as the prevalence of its use as adulterant is increasing [16], we strongly recommend the measurement of levamisole in cocaine-related deaths.

The highlighted differences in the packaging techniques, according to the different origin of the drug couriers obtained from the police investigation, permitted us to distinguish two different drug smuggling organizations operating and travelling to Italy. In general, drug trafficking organizations do not follow the same routes and the same packaging methods for all their transports. Indeed, routes and packaging seems to be influenced by the country of destination, the type of drug concealed and the financial resources of the organization, and no correlation between the type of drug concealed, the packaging techniques, and the drug smuggling routes has been demonstrated in literature [17,18].

Finally, the evidence of wax fragments in case 2, permitted us to hypothesize the presence of additional drug packages evacuated before the death of the drug courier. The presence of such fragments and the total absence of the substance has been explained with the presence of an accomplice who stole the drug.

3.1. Medico-legal issues When dealing with people suspected of body packing, a disparity between the medical purpose for hospital care and the police motivation where the focus is on obtaining legal proof of drug concealment is very frequent.

One of the most important medico-legal issue concerns the indications to perform a radiological examination in suspected body packers; this issue is handled in different ways depending on the country. Indeed, before examining a person suspected of drug smuggling, clinicians should be familiar with their country’s legislative framework regarding the use of imaging techniques without medical indications. The legislative framework differs across Europe and, more in general, across the world [19]. For example, in some countries (e.g., Hong Kong) informed consent must be obtained prior to undergoing the radiological examinations; whereas, in other countries (e.g., United Kingdom), informed consent is not required and radiological examinations may be performed at the request of a customs officer or following a judicial injunction.

The European Atomic Energy Community (Euratom) defines medico-legal purposes as “procedures performed for insurance or legal purposes without a medical indication� [20,21]. The aim of the Euratom directive was to ensure that individuals subjected to medico-legal procedures were guaranteed the same type of protection as patients.

Following the Euratom directive, medico-legal exposures to radiological examinations are regarded as a subset of medical exposures. For this reason they are not exempt from the public dose limit indicated in the directive [20].

Moreover, an important medico-legal issue concern the strategies adopted by body packers to prevent the radiologist from obtaining good diagnostic images. In most cases, body packers initially cooperate with the radiologists and give their informed consent to undergo the radiological examinations, but then they compromise the image quality by sabotaging the examinations, as they move, become agitated, or begin to breathe rapidly. Furthermore, other strategies adopted consists in the use of aluminum foil, plastic food wrap, carbon paper, or other materials, incorporated during the packaging procedure to reduce the radiodensity and minimize the risk of detection, and/or increasing the number of false negative imaging findings [22].

Finally, the eventuality of false positive and false negative radiological results provides the basis for further medicolegal issues. Indeed, a false negative finding will determine the release of the suspected smuggler and the successful delivery of the drug, which will be sold in the drug market. On the contrary, a false positive finding will result in the deprivation of the liberty of the suspected body packer, raising both an important ethical dilemma and a considerable extra costs due to the unnecessary detention.

4.

Conclusion

Two lethal cases of body packing has been described. The forensic examination of the drug packages highlighted important differences in their type and composition. These differences, due to the mechanical procedures adopted by drug smuggling organizations, allow body packer to reduce the risk of rupture and decrease the rate of drug couriers discovered by police officers. The two cases presented, even if occurred in a relatively small time frame, represent only a small amount of the real number of body packers travelling to Italy from countries with a high rate of drug traffic, such as the South America’s and North Africa’s ones. This high rate of drug traffic should also make the clinicians, and the forensic pathologists, aware of the main medico-legal issues that could arise from the in-hospital and out-of-hospital care of people suspected of drug smuggling.

References

1.

S. Cappelletti, D. Piacentino, C. Ciallella, Commentary on confounding definitions and descriptions of body packing, Abdom Imaging. 40 (2015) 3365-3366. doi: 10.1007/s00261-015-0541-6.

2.

S.J. Traub, R.S. Hoffman, L.S. Nelson, Body packing—the internal concealment of illicit drugs, N. Engl. J. Med. 349 (2003) 2519–2526.

3.

M. Shahnazi, H. Hassanian-Moghaddam, L. Gachkar, N. Ahmadi, N. Zamani, H. Bahrami-Motlagh, T. Faghihi Langroudi, A. Arjmand Shabestari, A. Mohammad Alizadeh, Comparison of abdominal computed tomography with and without oral contrast in diagnosis of body packers and body stuffers, Clin. Toxicol. (Phila) 53 (2015) 596-603. doi: 10.3109/15563650.2015.1054501.

4.

M.J. Bogusz, H. Althoff, M. Erkens, R.D. Maier, R. Hofmann, Internally concealed cocaine: analytical and diagnostic aspects, J. Forensic Sci. 40 (1995) 811–815.

5.

A.A. van Geloven, K.P. van Lienden, D.J. Gouma, Bodypacking--an increasing problem in The The Netherlands: conservative or surgical treatment?, Eur. J. Surg. 168 (2002) 404-409.

6.

N. Bulstrode, F. Banks, S. Shrotria, The outcome of drug smuggling by ‘body-packers’ - the British experience, Ann. R. Coll. Surg. Engl. 84 (2002) 35-38.

7.

R.R. Pidoto, A.M. Agliata, R. Bertolini, A. Mainini, G. Rossi, G. Giani, A new method of packaging cocaine for international traffic and implications for the management of cocaine body packers, J. Emerg. Med. 23 (2002) 149-153.

8.

S.O. Cawich, D. Hassranah, S. Pooran, D. Dan, V. Narayansingh, Complicated acute appendicitis? An unusual differential, Trop. Doct. 45 (2015) 49-51. doi: 10.1177/0049475514550064.

9.

A. Heinemann, S. Miyaishi, S. Iwersen, A. Schmoldt, K. Püschel, Body-packing as cause of unexpected sudden death, Forensic Sci. Int. 92 (1998) 1-10.

10. A.W. Jones, A. Holmgren, Concentration ratios of free-morphine to free-codeine in femoral blood in heroin-related poisoning deaths, Leg. Med (Tokyo). 13 (2011) 171-173. doi: 10.1016/j.legalmed.2011.02.002.

11. Methods for impurity profiling of heroin and cocaine, United Nations Office on Drugs and Crime. Available from: < https://www.unodc.org/pdf/publications/report_st-nar-35.pdf> (downloaded 19.02.2016).

12. S.J. Shea, Bioanalytical methods for quantitation of levamisole, a widespread cocaine adulterant, Clin. Chem. Lab. Med. 51 (2013) 205-212. doi: 10.1515/cclm-2012-0519.

13. C. Meissner, S. Recker, A. Reiter, H.J. Friedrich, M. Oehmichen, Fatal versus non-fatal heroin “overdose”: blood morphine concentrations with fatal outcome in comparison to those of intoxicated drivers, Forensic Sci. Int. 130 (2002) 49–54.

14. K. Slais, A. Machalova, L. Landa, D. Vrskova, A. Sulcova, Could piracetam potentiate behavioural effects of psychostimulants?, Med. Hypotheses 79 (2012) 216-218. doi: 10.1016/j.mehy.2012.04.041.

15. EMCDDA Annual report 2010: the state of the drugs problem in Europe, European Monitoring Centre for Drugs and Drug Addiction. Available from: <http://www.emcdda.europa.eu/online/annual-report/2010/boxes/p66> (downloaded 19.02.2016).

16. C. Eiden, H. Peyrière, C. Diot, O. Mathieu, Prevalence of levamisole and aminorex in patients tested positive for cocaine

in

a

French

University

10.3109/15563650.2015.1054499.

Hospital,

Clin.

Toxicol.

(Phila).

53

(2015)

604-608.

doi:

17. M. Nihira, M. Hayashida, Y .Ohno, S. Inuzuka, H. Yokota, Y. Yamamoto, Urinalysis of body packers in Japan, J. Anal.

Toxicol. 22 (1998) 61-65.

18. K. Uekusa, M. Hayashida, N. Saito, K. Mashiko, K. Hara, B. Waters, Y. Ohno, Methamphetamine and amphetamine concentrations in survivors of body-packer sundrome in Japan, For. Sci. Int. 227 (2013) 45-47.

doi:

10.1016/j.forsciint.2012.10.005.

19. R.J. Booker, J.E. Smith, M.P. Rodger, Packers, pushers and stuffers--managing patients with concealed drugs in UK emergency departments: a clinical and medicolegal review, Emerg. Med. J. 26 (2009) 316-320. doi: 10.1136/emj.2008.057695.

20. Dangers arising from ionising radiation [Internet], Council Directive 96/29/Euratom, European Union. Available from: <http://europa.eu/legislation_summaries/employment_and_social_policy/health_hygiene_safety_at_work/c11142_en.ht m> (downloaded 19.02.2016).

21. Council Directive 84/466/Euratom of 3 September 1984 on health protection of individuals against the dangers of ionizing radiation in relation to medical exposure, European Union. Available from: <http://eur-lex.europa.eu/legalcontent/EN/TXT/PDF/?uri=CELEX:31997L0043&from=EN> (downloaded 19.02.2016).

22. M. Shahnazi, M. Sanei Taheri, R. Pourghorban, Body packing and its radiologic manifestations: a review article, Iran. J. Radiol. 8 (2011) 205-210. doi: 10.5812/iranjradiol.4757.

Table 1. Toxicological findings

Case # 1 Morphine Codeine 6-MAM Piracetam

Case # 2 Cocaine BEG EME Levamisole Diazepam Nordiazepam Temazepam Lorazepam THCA

Peripheral blood

Urine

Bile

Gastric content

0.8 -

11 -

42 -

5.9 2.4 1.4

tr

tr

tr

tr

4.4 22.5 7.8 0.2 0.2 0.03

259 222 206 0.7 0.4 0.2 0.1 0.3

96 31 48.8 -

1200* -

Table 1. Data were rounded to one decimal place; all values are expressed in mg/L. 6-MAM: 6-monoacetylmorphine; tr: traces; BEG: Benzoylecgonine; EME: ecgonine methyl ester; THCA: Tetrahydrocannabinolic acid; * Value obtained from the analysis of the liquid part of the gastric content.

Figures legends Fig. 1. Postmortem radiography showing multiple packages with a surrounding thin rim of halo, producing the â&#x20AC;&#x153;double condom signâ&#x20AC;?. The halo is produced by the air trapped between the dense packet content and the outermost wrapping layer.

Fig. 2. Forensic examination of drug packages in the cases presented. A) Case 1 showing undamaged packages wrapped with a condom and two layers of plastic film; B) Case 2 showing damaged and undamaged packages wrapped from outside to inside with: red wax, cellophane and latex.

Figure 1

Figure 2

Highlights -

Two cases of body packers has been presented.

-

Different packaging techniques, among the two cases, has been identified.

-

The main medico-legal issues related to body packing has been described.

Keywords: Body packer; Cocaine; Drug concealment; Forensic toxicology; Heroin; Piracetam.

Abstract: Body packing is a general term used to indicate the internal transportation of drug packages, mainly cocaine, heroin, amphetamines, and methamphetamine, within the gastrointestinal tract.

We described two cases of accidental drug intoxication, observed over the last year period, with evidence of intracorporeal drug concealment. The first case concerned a body packer transporting 69 drug packages of heroin adulterated with piracetam. The second body packer transported 16 drug packages of cocaine adulterated with levamisole. For both cases, forensic examination and toxicological analysis of drug packages and biological samples were carried out. Authors also wants to highlight the main medico-legal issues that commonly arise in cases of suspected or ascertained body packers.