Systematic Review of Drug Packaging Methods in

REVIEW ARTICLE

Systematic Review of Drug Packaging Methods in Body Packing and Pushing A Need for a New Classification Simone Cappelletti, MD,*† Daria Piacentino, PhD,‡ and Costantino Ciallella, MD*

Abstract: A systematic review of the literature regarding drug packaging methods in body packing and materials used is presented, with the aim (a) to summarize data regarding the packaging methods adopted by drug trafficking organizations, (b) to support forensic pathologists and police forces to classify and describe drug packages, (c) to propose a new classification for drug packaging techniques, and (d) to better clarify the impact of packaging methods on radiological detectability. Packaging methods have been described in 2981 cases, permitting us to summarize the different materials used and to propose a new classification for packaging method based on the materials used. Information concerning the affiliation of body packers and pushers with major (or not) drug trafficking organizations and techniques used to reduce the radiological detectability of the concealed drugs have also been collected. Besides the packaging methods described over the years, our study suggests a standardized approach for the description of drug packages based on the use of different materials and packaging procedures, which provide a possible insight to the type of drug trafficking organization involved. Key Words: body packer, body pushing, drug packages, packaging method, drug traffic organization

undetected cases is undoubtedly high and, consequently, it is difficult to identify the countries involved in exporting drug through these methods. Researchers and policy makers are making an effort to understand the body packers' or pushers' business operations to better design and target police efforts and reduce the harm associated with this illicit market. A better comprehension of this phenomenon was made possible by the analysis of the drug packages' materials and characteristics. The latter may help police forces to retrace the drug traffic pathways. The aim of this systematic review is to summarize data regarding the packaging methods adopted by drug trafficking organizations to smuggle drugs via body packing or pushing. We also aim to suggest a new classification of packaging methods based on the results of the systematic review and better clarify the impact of packaging methods on radiological detectability, that is, up to now, one of the most important ways to identify drug smuggling. This is to support forensic pathologists and police forces to classify and describe drug packages, which will enable the identification of the supply routes adopted by Drug Trafficking Organizations (DTOs) to produce drug packages.

(Am J Forensic Med Pathol 2018;00: 00–00)

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nternal concealment and transportation of illegal substances by body packing or pushing are a major business with very high profits, attracting criminals all over the world. Body packing is a general term used to indicate the internal transportation of drug packages within the gastrointestinal tract; body pushing refers to the insertion of drug packages in various anatomical cavities and body orifices, such as the anus, the vagina, and the ears.1 It is common for body packers to be hired specifically to smuggle drugs across continents and for body pushers to smuggle drugs across national frontiers or prisons; in both cases, there could be a history of international traveling originating in countries known for drug producing or drug selling. The main illegal substance transported by these methods is cocaine, followed by heroin, methamphetamine, and cannabinoids.2 Because body packers are rarely arrested, their proportion in the general population remains unknown. The percentage of

Manuscript received July 28, 2018; accepted August 22, 2018. From the *Legal Medicine Section – SAIMLAL Department, Sapienza University of Rome; † State Police Health Service Department, Ministry of Interior; and ‡ NESMOS Department, School of Medicine and Psychology, Sant'Andrea Hospital, Sapienza – University of Rome, Rome, Italy. This study complied with ethical standards. No ethical approval was obtained because this study did not involve a prospective evaluation, did not involve laboratory animals, and did not involve invasive procedures. The authors report no conflict of interest. Reprints: Simone Cappelletti, MD, Viale Regina Elena, 336 – 00161 Rome, Italy. E-mail: [email protected]. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0195-7910/18/0000–0000 DOI: 10.1097/PAF.0000000000000436

Am J Forensic Med Pathol • Volume 00, Number 00, Month 2018

METHODS Eligibility Criteria This systematic review was carried out according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) standards.3 Studies examining the drug packaging methods in body packers and pushers were included. Study designs included case reports, case series, retrospective and prospective studies, letters to the editors, and reviews. The latter were consulted to search in their reference lists other eligible articles; however, this activity did not produce relevant results. The search was limited to human studies.

Search Criteria and Critical Appraisal A systematic literature search and a critical appraisal of the collected studies were conducted. An electronic search of PubMed and ScienceDirect Scopus from the inception of these databases to the August 14, 2018, was performed. Search terms were “body packing” OR “body pushing” OR “body packer” OR “body pusher” in title, abstract, and key words. The term “body stuffer” was not included in the research, because it refers to drug users or street dealers who, on the verge of arrest by police or for the fear of it, swallow the evidence because they are unable to throw it away. Furthermore, it always represents an improvised packaging method, not consistent with the purposes of our study. All the articles were reviewed taking into account only the packaging information (if present), so that we analyzed both survived (apprehended or with drug toxicity symptoms) and deceased drug smugglers. The bibliographies of all located articles were examined and cross-referenced for further relevant literature. Methodological appraisal of each study was conducted according to the PRISMA www.amjforensicmedicine.com

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Cappelletti et al


standards, including evaluation of bias. Data collection entailed study selection and data extraction. Two researchers (S.C., D.P.) independently examined those articles whose title or abstract seemed to be relevant and selected the ones that analyzed the composition and/or the method of drug packaging. Disagreements concerning eligibility between the researchers were resolved by consensus process. No unpublished or gray literature was searched. Data extraction was performed by one investigator (S.C.) and verified by another investigator (C.C.). This study was exempt from institutional review board approval because it did not involve human subjects.

Risk of Bias

RESULTS Search Results and Included Studies An appraisal based on titles and abstracts as well as a hand search of reference lists was carried out. The reference lists of all articles were reviewed to detect unidentified literature. Figure 1 illustrates our search strategy. A total of 202 studies fulfilled the inclusion criteria, producing a pooled data set of 9044 individuals, with cluster ranging from 1 (ie, case reports) to 1250 individuals (ie, a retrospective study), with a mean of 46.4 and a median of 1 individual, indicating skewness toward smaller samples.

Study Characteristics The following data were extracted from the included studies: study source, study type, transported drugs, packaging method (if described), location of the packages (if described), and technique of transportation. A data collection form was developed and used to extract data from the included studies. An exhaustive summary of the literature, including extracted data, is shown in Table 1.

This systematic review has a number of strengths that include the amount and breadth of the studies, which span the globe, the hand search and scan of reference lists for the identification of all relevant studies, and 2 flowcharts that describe in detail the study selection process. It must be noted that this review includes studies that were published during a time frame of 45 years; thus, despite our efforts to fairly evaluate the existing literature, the results of this study should be interpreted taking into account that the accuracy of the packaging description is not always the main target of the author describing the case of body packers or pushers. As a result, a number of articles, mainly case reports, lack packaging method descriptions or report incomplete data (eg, only the material used without the description of how it was used). Thus, we chose to cite only those articles in which the packaging method was sufficiently clear.

Drug Packaging Methods Classification Classification of packaging methods evolved throughout the years; in 1983, McCarron et al202 attempted a first categorization based on the risk of rupture and the number of coverage layers, which included the following 3 types of packages: • Type 1 are highly susceptible to leakage or rupture—these packages contain loosely packed drug covered with 2 to 4 layers of wrapping, usually made of a condom tied at one end, folded back over itself, and tied again at the opposite end;

The other 2 packages consist in a condom wrapped with masking tape to create a small bundle, with the bundle covered with 2 or more condoms and tied with fishing line or similar devices, more specifically:

FIGURE 1. PRISMA flowchart of included and excluded studies.

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Canada United States

United States United States

United States United States United States

Australia United States

Sweden

United States

Australia Germany United States Belgium Canada United States

Finland

United States United States Belgium United Kingdom France

Lopez et al (1974)6 Freed et al (1976)7

Fainsinger (1977)8 Suarez et al (1977)9 Bettinger (1980)10

Vowels and Harvey (1980)11 Fishbain and Wetli (1981)12

Sinner (1981)13

Wetli and Mittlemann (1981)14

Dunne (1983)15 Rauber and Müller (1983)16 Caruana et al (1984)17 Kersschot et al (1985)18 Joynt and Mikhael (1985)19 Beerman et al (1986)20

Pamilo et al (1986)21

Amon et al (1986)22 Winek et al (1987)23 Hartoko et al (1988)24 Lancashire et al (1988)25 Gherardi et al (1988)26

Country

Deitel and Syed (1973)4 Mebane and De Vito (1975)5

First Author/s (Year of Publication)


Case report (n = 1) Case report (n = 1) Case series (n = 7) Case report (n = 1) Retrospective (n = 120)

Case series (n = 4)

Case series (n = 3) Retrospective (n = 16) Retrospective (n = 50) Case series (n = 5) Case report (n = 1) Retrospective (n = 53)

Case series (n = 11)

Case series (n = 4)

Case series (n = 3) Case report (n = 1)

Case report (n = 1) Case series (n = 3) Case report (n = 1)

Case report (n = 1) Case report (n = 1)


Study Type (No. Participants)

Cocaine Cocaine Cocaine Cocaine 68 heroin/52 cocaine

3 heroin/ 1 heroin + hashish

Heroin Cocaine/hashish Drugs not reported Cocaine Heroin Drugs not reported

Cocaine

Heroin/cocaine/marijuana

Hashish oil Cocaine

Cocaine Cocaine Cocaine

Hashish oil Cocaine

Hashish Cocaine

Transported Drug/s

TABLE 1. Data Items Extracted From the Selected Studies Involving Drug Packaging Methods

Not reported Not reported Not reported Not reported Not reported

Small bowel and ascending colon Not reported

Bowel Vagina Rectum Not reported Not reported Not reported Not reported

Not reported

Not reported Pylorus and cecum

Stomach Stomach and small bowel Not reported Stomach Not reported

Small bowel Not reported

Location of the Packages

Body packing Body packing Body packing Body packing Body packing

Body packing

Body packing

Body packing Body packing Body packing Body packing

Body packing Body pushing

Body packing

Body packing Body packing

Body packing Body packing Body packing



Technique of Transportation



Continued next page

Plastic foil Aluminum foil Condom No description No description No description No description Cellophane Latex Aluminum foil Carbon paper Self-adhesive tape Condom Plastic foil Rubber bag

Latex bag Condom Finger cot Balloon Condom Finger cot Aluminum foil Condom Capsule Balloon Condom Plastic bag Condom Balloon No description Balloons Condom Condom

Condom Finger cot Balloon Balloon Balloon

Material(s) Used for Packaging

Am J Forensic Med Pathol • Volume 00, Number 00, Month 2018 Systematic Review of Drug Packaging Methods

3

4

Switzerland

Germany

Belgium Austria United States

France France

United Kingdom

United States

Finland United Kingdom Spain Switzerland United Kingdom Italy United States

Canada United States

United Kingdom Germany Germany United States United Kingdom Italy

Japan

Wehr and Alzen (1989)28

Geyskens et al (1989)29 Hannesschläger et al (1989)30 Introna and Smialek (1989)31

Gherardi et al (1990)32 Marc et al (1990)33

Stewart et al (1990)34

Sherman and Zingler (1990)35

Karhunen et al (1991)36 Watson et al (1991)37 Luburich et al (1991)38 John et al (1992)39 Horrocks (1992)40 Aldrighetti et al (1993)41 Utecht et al (1993)42

Meatherall and Warren (1993)43 Benjamin et al (1994)44

Glass and Scott (1995)45 Bogusz et al (1995)46 Hierholzer et al (1995)47 Leo et al (1995)48 Patel (1996)49 Aldrighetti et al (1996)50

Ichikawa et al (1997)51

Country

Deuel et al (1989)27


TABLE 1. (Continued)



Retrospective (n = 23)

Case series (n = 5) Retrospective (n = 30) Case series (n = 12) Case report (n = 1) Case report (n = 1) Retrospective (n = 61)


Case series (n = 82) Case report (n = 1) Case series (n = 16) Case report (n = 1) Prospective (n = 158) Case report (n = 1) Case series (n = 14)

Case report (n = 1)

Case report (n = 1)

Case report (n = 1) Case series (n = 23)

Case report (n = 1) Case series (n = 2) Case series (n = 7)

Case report (n = 1)



16 cannabis/5 cocaine/ 2 heroin

4 cocaine/1 heroin Cocaine Cocaine Heroin Cocaine Cocaine

Hashish oil Cocaine

Drugs not reported Amphetamine 6 heroin/5 cocaine/ 5 cannabis Cocaine Cocaine Cocaine Heroin

Cocaine

Heroin

Cocaine Cocaine

Cocaine Cocaine 5 cocaine/2 heroin

Cocaine

26 cocaine/25 heroin

Transported Drug/s

Not reported

Not reported Not reported Not reported Stomach and colon Not reported Bowel

Not reported Vagina

Not reported Not reported Not reported Not reported Not reported Not reported Not reported

Stomach

Not reported

Bowel Not reported

Descending colon and rectum Not reported Not reported Not reported

Rectum


Body packing

Body packing Body packing Body packing Body packing Body packing Body packing

Body packing Body pushing

Body packing Body packing Body packing Body packing Body packing Body packing Body packing

Body packing

Body packing



Body packing Body pushing Body packing


Rubber balloon Plastic bag No description Cellophane Latex Carbon paper Self-adhesive tape Condom Masking tape Surgical latex finger cot Cellophane Dental floss No description Condom No description No description No description No description Black electrician's tape Glove latex Balloon Condom Condom Yellow masking tape Condom No description Electrical tape No description Condom Latex tubing Aluminum foil Plastic food wrap Carbon paper No description

Rubber bag Plastic foil No description Condom Condom

No description


Cappelletti et al Am J Forensic Med Pathol • Volume 00, Number 00, Month 2018


United States

United States Spain United States Netherlands Germany

Japan

Lebanon United Kingdom Israel United States

Israel Austria

Israel France United States Portugal Canada United Kingdom

Italy

Netherlands Italy United States

Netherlands Netherlands United Kingdom

Wetli et al (1997)52

Choudhary et al (1998)53 Gómez Antúnez et al (1998)54 Miller et al (1998)55 Visser et al (1998)56 Heinemann et al (1998)57

Nihira et al (1998)58

Farah and Ghayad (1999)59 Krishnan and Brown (1999)60 Yanai and Hiss (1999)61 Hutchins et al (2000)62

Klein et al (2000)63 Stichenwirth et al (2000)64


Greenberg et al (2000)65 Clément et al (2001)66 Olmedo et al (2001)67 Macedo and Ribeiro (2001)68 Brown et al (2002)69 Bulstrode et al (2002)70

Pidoto et al (2002)71

Van Geloven et al (2002)72 Furnari et al (2002)73 Gill and Graham (2002)74

Fassaert and Visser (2003)75 Meijer and Bots (2003)76 Swan et al (2003)77


Case series (n = 4) Prospective (n = 50) Case series (n = 2)

Retrospective (n = 40) Case report (n = 1) Retrospective (n = 50)

Prospective (n = 161)

Case report (n = 1) Case report (n = 1) Case series (n = 2) Case report (n = 1) Case report (n = 1) Retrospective (n = 180)


Case report (n = 1) Case report (n = 1) Case series (n = 2) Case series (n = 3)

Case series (n = 9)

Case report (n = 1) Retrospective (n = 215) Case report (n = 1) Case report (n = 1) Case series (n = 4)


Cocaine Cocaine 42 heroin/4 cocaine/ 4 heroin + cocaine Cocaine Cocaine Cocaine

Cocaine

Cocaine Cocaine 1 cocaine/1 heroin Cocaine Heroin Cocaine/heroin

Cocaine Cocaine

5 cocaine/2 heroin/1 opium/ 1 marijuana Cocaine Ecstasy tablets Cocaine Heroin

Cocaine Cocaine Cocaine Cocaine 2 cocaine/1 heroin/ 1 amphetamine

Heroin

Not reported Not reported Not reported


Not reported

Not reported Not reported Not reported Esophagus Not reported Not reported

Not reported Not reported

Not reported Rectum Not reported Not reported

Not reported

Not reported Not reported Stomach Not reported Not reported

Not reported



Body packing



Body packing Body pushing Body packing Body packing

Body packing


Body packing


Continued next page

No description Condom No description

Latex Cellophane Condom Dental floss Wax No description No description No description Latex Balloon fingerstall Condom Plastic bag Aluminum foil Cellophane Rubber wax No description Plastic surprise egg No description Cellophane Latex Plumbing tape Black electrical tape Finger of rubber glove Plastic foil Latex Wax No description Condom No description Plastic bag Plastic bag Condom Polythene plastic kitchen wrap Tubular latex Paraffin Fiberglass No description Latex Plastic foil No description


5

6

Turkey United States

United States Kenya Norway

United States France Italy United Kingdom

India

Poland United Kingdom Qatar Australia

Spain United States Poland United Kingdom China United States Thailand United States

Iran Pakistan

Japan

Jamaica Puerto Rico Italy United Kingdom

Traub et al (2003b)80 Olumbe (2004)81 Aksnes and Jacobsen (2004)82

Mégarbane et al (2004)83 Fucci (2004)84 Havis et al (2005)85

Chappidi et al (2005)86

Ciszowski et al (2005)87 Karkos et al (2005)88 Khan (2005)89 Low and Dillon (2005)90

Ortega-Carnicer et al (2005)91 Koehler et al (2005)92 Sein Anand et al (2005)93 Chakrabarty et al (2006)94 Chung and Fung (2006)95 Cordero et al (2006)96 Sribanditmongkol et al (2006)97 Algra et al (2007)98

Shadnia et al (2007)99 Sohail (2007)100

Takekawa (2007)101

Cawich et al (2008)102 De Jesus-Monge (2008)103 Marchei et al (2008)104 Sengupta and Page (2008)105

Country

Kocakuşak A et al (2003)78 Traub et al (2003a)79





Case report (n = 1) Case report (n = 1) Case series (n = 64) Case report (n = 1)

Case report (n = 1)

Case report (n = 1) Case series (n = 11)

Case report (n = 1) Case report (n = 1) Case report (n = 1) Case report (n = 1) Case report (n = 1) Case report (n = 1) Retrospective (n = 2) Retrospective (n = 605)

Case report (n = 1) Case report (n = 1) Case report (n = 1) Case series (n = 5)

Case report (n = 1)

Case report (n = 1) Case series (n = 17) Case report (n = 1) Retrospective (n = 16)

Case series (n = 1) Case series (n = 1) Case series (n = 4)

Case series (n = 2) Case report (n = 2)


Cocaine Heroin 63 cocaine/1 heroin Heroin

Methamphetamine

Heroin Drugs not reported

Cocaine Cocaine Cocaine Heroin Drugs not reported Cocaine Heroin Cocaine

Cocaine Heroin Cocaine Methamphetamine

No transported drug Heroin 2 cocaine/ 1 amphetamine + LSD/ 1 drug not described Heroin + cocaine Cocaine Cocaine Cocaine/amphetamine/ cannabis Heroin

Drugs not reported Heroin

Transported Drug/s

Rectum and sigma Not reported Not reported Colon and rectum

Stomach

Colon Not reported Stomach Not reported Stomach Not reported Stomach Small bowel, colon and rectum Not reported Ileum and ascending/ transverse colon

Ileum and transverse colon Not reported Esophagus Stomach and rectum Not reported


Body packing


Body packing Body packing Body packing Body packing Body packing Body packing Body packing Body packing


Body packing


Body packing

Not reported Not reported Not reported Stomach and intestine Not reported

Body packing



Not reported

Not reported Stomach


No description Latex balloon Aluminum Plastic foil Plastic film Scotch tap No description No description No description Beeswax Condoms

No description Condom Condom Rubber balloons ‘ cling-wrap’-type plastic Latex Plastic wrapped Scotch tape No description Plastic bag Condom No description No description

No description

No description No description No description No description

No description Wax Latex Plastic food wrap No description No description No description




Case series (n = 2) Case report (n = 1) Case report (n = 1) Case report (n = 1)

Spain

Pakistan United Kingdom United States

Iran Spain Iran China China

Germany

United Kingdom France Greece Switzerland Belgium United States

Italy France Australia

Spain Netherlands

Italy Ireland Switzerland

Madrazo González et al (2009)112 Naseem and Abbas (2009)113 Peake et al (2009)114 Saha (2009)115

Sanaei-Zadeh (2009)116 Soriano-Perez et al (2009)117 Taheri et al (2009)118 Yang et al (2009)119 Li et al (2009)120

Albert et al (2010)121


Niewiarowski et al (2010)122 De Prost et al (2010)123 Njau et al (2010)124 Beauverd et al (2011)125 Hantson et al (2011)126 Mandava et al (2011)127

Rossi et al (2011)128 Spadari et al (2011)129 Wilcher (2011)130

Burillo-Putze et al (2012)131 De Bakker et al.(2012)132

Giuliani et al (2012)133 Ní Chróinín and Gaine (2012)134 Flach et al (2012)135


Case report (n = 1) Case report (n = 1) Retrospective (n = 83)

Case series (n = 2) Retrospective (n = 143)

Case report (n = 1) Case series (n = 2) Case series (n = 5)

Retrospective (n = 285) Case report (n = 1) Case report (n = 1) Case report (n = 1) Case report (n = 1) Retrospective (n = 1250)

Case report (n = 1)

Case report (n = 1) Case report (n = 1) Case report (n = 1) Retrospective (n = 158) Case report (n = 1)

Retrospective (n = 351) Case report (n = 1) Case report (n = 1)

United Kingdom Portugal Israel

Beckley et al (2009)109 Dinis-Oliveira et al (2009)110 Israelit et al (2009)111

Case series (n = 12) Retrospective (n = 1181) Retrospective (n = 27)

Iran France Brazil

Taheri et al (2008)106 Veyrie et al (2008)107 Modelli et al (2008)108

Cocaine Cannabis 3 heroin/1 cocaine/ 1 methadone + BDZ Liquid cocaine 116 cocaine/3 heroin/ 1 marijuana/ 23 drugs not reported Cocaine Cocaine Cocaine

Drugs not reported Cocaine Heroin Cocaine Cocaine Cocaine/heroin

Cocaine

Opium Hashish Opium Heroin Methamphetamine

Heroin Cocaine Heroin

Opium Drugs not reported 20 marijuana/4 antipsychotics/3 cocaine Cocaine Cocaine Cocaine + cannabis + amphetamine Cocaine


Not reported Not reported

Stomach Not reported Not reported

Not reported Not reported Ascending and transverse colon Bowel Not reported Not reported Not reported Esophagus, stomach and small bowel Stomach and small bowel Not reported Not reported Not reported Not reported Stomach and rectum Not reported

Not reported Not reported Stomach, duodenum, jejunum and rectum Bowel vagina






Body packing


Body packing Body pushing Body packing Body packing Body packing




Continued next page

No description No description Black rubber coated

Aluminum Latex Plastic material Plastic container No description Latex glove Paraffin Condom Finger sleeve Cellophane Surgical finger cot Cellophane Cellophane Glass ampoule Condom No description

No description No description No description No description Tinfoil Plastic film Plastic wrapping

No description No description No description

No description

No description Transparent scotch tape No description

No description No description No description


7

8


Case report (n = 1) Retrospective (n = 67)

India Turkey

Turkey

Switzerland The Netherlands Greece Israel

Bulakci et al (2013b)148

Fornaro et al (2013)149 Dorn et al (2013)150 Panagoulias et al (2013)151 Markovits et al (2013)152


Retrospective (n = 45) Case report (n = 1)

Malaysia France Japan Italy Israel

Mauritius

Belgium

Spain

Nizam et al (2013)155 Rousset et al (2013)156 Uekusa et al (2013)157 Covarelli et al (2014)158 Mozes et al (2014)159

Gungadin and Ananda (2014)160 Hantson et al (2014)161

Álvarez Llano et al (2014)162


Case report (n = 1) Prospective (n = 138) Case series (n = 3) Case series (n = 2) Retrospective (n = 25)

Brazil India

Neves et al (2013)153 Jakhar et al (2013)154 Case report (n = 1) Case report (n = 1)

Case series (n = 8) Retrospective (n = 707) Case series (n = 2) Retrospective (n = 23)


Case report (n = 1) Case report (n = 1) Case report (n = 1)

Case report (n = 1) Case report (n = 1) Retrospective (n = 8) Prospective (n = 330) Retrospective (n = 279)

India Australia Germany Switzerland Finland

Israel Germany Malaysia

Case report (n = 1)

Iran

Mehrpour and Sezavar (2012)137 Kulkarni et al (2012)138 Mitra et al (2012)139 Pache et al (2012)140 Poletti et al (2012)141 Sormaala et al (2012)142

Zeina et al (2012)143 Walter et al (2012)144 Bin Abdul Rashid et al (2013)145 Sureka et al (2013)146 Bulakci et al (2013a)147

Case report (n = 1)


Switzerland

Country

Klenke et al (2012)136



Drugs not reported

Cocaine

43 heroin/2 cannabis

Methamphetamine Cocaine Methamphetamine 1 cocaine/1 heroin Cocaine

Cocaine 31 cocaine/ 11 crack cocaine/ 8 methamphetamine/ 2 heroin 8 cocaine/ 3 crack cocaine/ 2 methamphetamine Cocaine Drugs not reported Cocaine 13 cocaine/ 3 liquid cocaine/ 2 hashish/ 1 drug not reported Cocaine Heroin

Heroin Cocaine Methamphetamine

Cocaine Heroin Cocaine 50 cocaine/ 3 rolls of banknotes Drugs not reported

Heroin

Drugs not reported

Transported Drug/s

Esophagus, stomach, sigmoid, and rectum Not reported

Not reported

Stomach Not reported Not reported Stomach and duodenum Not reported

Rectum and sigmoid Stomach, small and large bowel

Not reported Not reported Stomach Not reported

Not reported

Stomach and bowel Not reported Stomach and transverse colon Not reported Not reported

Stomach and jejunum Small bowel Not reported Not reported Not reported

Cecum and ascending colon Stomach and colon


Body packing

Body packing

Body packing


Body pushing Body packing


Body packing


Body packing

Body packing


Body packing

Body packing


No description

No description Polythene piece Balloon rubber Cellophane tape No description No description No description No description Cellophane Condom Cellophane Wax No description

No description No description No description Latex Clinging plastic

No description

No description No description

Electrical tape No description No description No description Plastic surprise egg Condom No description No description No description

No description

No description




Turkey

Iran Germany Italy Turkey Portugal Germany Australia Australia Italy Turkey

Switzerland Iran

Portugal United States United States Trinidad & Tobago Iran India

United Kingdom

Germany Belgium Iran Iran Serbia Italy

Italy Iran Germany

Kucukmetin et al (2014)163

Sanaei-Zadeh (2014)164 Schulz et al (2014)165 Simioni et al (2014)166 Kumral et al (2014)167 Coelho et al (2014)168 Aissa et al (2015)169 Asha and Cooke (2015)170 Asha et al (2015)171 Covarelli et al (2015)172 Cengel et al (2015)173

Janczak et al (2015)174 Shahnazi et al (2015)175

Trabulo et al (2015)176 Devine (2015)177 Shields et al (2015)178 Cawich et al (2015)179 Montazeri (2016)180 Pramanik and Vidua (2016)181

Alfa-Wali et al (2016)182

Aissa (2016)183 Ngatchou et al (2016)184 Alipour-Faz et al (2016)185 Bahrami-Motlagh et al (2016)186 Brajković et al (2016)187 Cappelletti et al (2016)188

Visonà et al (2017)189 Najafi and Montazeri (2017)190 Aissa et al (2017)191

Cocaine


Case report (n = 1) Case report (n = 1) Retrospective (n = 80)

Retrospective (n = 108) Case report (n = 1) Retrospective (n = 175) Retrospective (n = 40) Case report (n = 1) Case series (n = 2)


Case report (n = 1) Case report (n = 1) Case report (n = 1) Case report (n = 1) Case report (n = 1) Case report (n = 1)

Heroin Heroin Cocaine

Drugs not reported Cannabis Crack/heroin/opium/crystal Drugs not reported Cocaine 1 cocaine/1 heroin

Drugs not reported

Cocaine Heroin Cocaine Cannabis Opium Cocaine

Opium Drugs not reported Opium Heroin Cocaine Cocaine Drugs not reported Drugs not reported Cocaine/heroin 26 cocaine/ 7 liquid cocaine/2 heroin Case report (n = 1) Cocaine Prospective (n = 11 body Drugs not reported packers on 35 total)

Case report (n = 1) Retrospective (n = 38) Case report (n = 1) Case report (n = 1) Case report (n = 1) Retrospective (n = 99) Retrospective (n = 60) Retrospective (n = 50) Case series (n = 5) Prospective (n = 45)

Case report (n = 1)


Not reported Not reported Not reported Not reported Not reported Esophagus, stomach, duodenum, colon, and rectum

Not reported

Colon Colon Rectum Cecum Rectum Stomach, small and large bowel

Transverse colon Not reported

Stomach and small bowel Colon Not reported Sigmoid Not reported Stomach Not reported Not reported Not reported Not reported Not reported



Body packing



Body packing Body packing Body packing Body packing Body packing Body packing Body packing Body packing Body packing Body packing

Body packing


Continued next page

Plastic bag Nylon Cellophane Plastic thimble No description Capsule Latex No description No description Aluminum foil Tubular latex Cellophane Paraffin Cling film Condom Latex No description No description No description No description No description Condom Plastic film Red wax Cellophane Latex Cellophane No description No description

No description No description No description No description No description No description No description No description Adhesive tape No description

No description



9


10

The type 3 packages described by McCarron et al202 underwent further depiction by Traub et al,79 who identified newer type 3–like packages, with standard dimensions and weight, indicating a mechanical manufacturing process starting with highly compressed drug powder encased in several layers of latex and finished with layers of wax. In 2002, Pidoto et al71 illustrated another type of drug packaging:

Not reported Not reported Not reported Not reported

• Type 4 are industrial packages used for cocaine only, prepared by dissolving cocaine hydrochloride in an alcohol-water solution and placing the resulting dense paste in a specific device and, when hardened, packed in tubular latex. Preparation is completed by covering the package with colored paraffin or fiberglass.

The last development was reported in 2017 by Visentin et al,192 who first described a technique that we have called “matryoshka-like” (type 5 packages). It consists of an external multilayer cellophane casing, containing multiple smaller packages of hardened heroin powder, each one covered with cigarette paper and multiple layers of heat-sealed cellophane. This packaging method does not seem to be used by major DTOs, because the wrapping type is not safe and its structure does not guarantee a low radiological detectability risk, being, on the contrary, easily detectable using a simple abdominal x-ray examination.

Cocaine Cannabis Hashish Heroin

Drug Packaging Methods Analysis

BDZ indicates benzodiazepines; LSD, lysergic acid diethylamide.

Switzerland Spain Spain India Flach et al (2017)198 Tung Chen and Elgeadi Saleh (2017)199 Supervía Caparrós et al (2017)200 Ray et al (2018)201

Case report (n = 1) Case report (n = 1) Case report (n = 1) Case report (n = 1)

Australia India Byard and Kenneally (2017)196 Wankhade and Chikhalkar (2017)197


• Type 2 are characterized by a larger size and consist of a bundle of tightly packed drug covered with 5 to 7 layers of tubular latex or latex gloves and tied tightly with a knot at each end; • Type 3 are similar to type 2 packages, but they are wrapped in aluminum foil and overwrapped with 3 to 5 layers of tubular latex securely tied at both ends.

Adhesive tape No description No description No description

Plastic film No description

Body pushing Body packing Body pushing Body packing Body packing Body packing Body packing Nitrazepam Cocaine

United States Esterson YB (2017)195


Turkey Asil and Dertli (2017)194

Case report (n = 1)

Cocaine

Stomach, ascending colon and rectum Rectum Bowel vagina

Body packing

Cigarette paper Plastic Plastic capsule Body packing Stomach

Switzerland Heymann-Maier et al (2017)193

Case report (n = 1)

79 cocaine 1 heroin 1 methamphetamine 52 not identified Heroin Retrospective (n = 148)

Not reported

Body packing

Cellophane Cigarette paper No description Body pushing Rectum Heroin Case report (n = 1) Italy Visentin et al (2017)192



Country


Transported Drug/s




Cappelletti et al

Among the 9045 cases described in the 202 articles reviewed, we were able to identify the packaging method in 2981 cases. In the remaining 6064 cases, packaging details were not reported, because the main aim of the authors was the description of the imaging and/or toxicological findings, regardless of the used packaging method. Among the 202 articles reviewed, body pushing has been described only in 9 articles, showing the low frequency of this technique probably due to the scarce quantity of drug that could be smuggled in this way. To our knowledge, up to now, no article has investigated systematically the drug packaging methods that are used in body packing and pushing. Data included in Table 1 allowed us to provide a new classification of drug packaging methods based on (a) the materials used for wrapping and (b) the use of extemporary handmade or machine-based packaging procedures (Table 2). During article review, we noticed that the description of the materials used for wrapping was inconsistent. For example, we found an overlapping use of the terms “rubber balloon” and “plastic balloon” to indicate the same material.154,174 In addition, many authors used the term “scotch tape” instead of “masking tape” or “self-adhesive tape” to describe the same material.34,44,93,101,110 A number of packaging methods are universally adopted by drug mules, independently from the transported drug, whereas others can be considered specific for some drugs. Indeed, even if the use of condom, aluminum, cellophane, latex, and rubber is widespread for every kind of drug transported © 2018 Wolters Kluwer Health, Inc. All rights reserved.



TABLE 2. Packaging Methods Classifications Packaging Methods Classification by Materials Condom-based Finger cot-based Condom Finger cot Condom and plastic foil Finger cot and cellophane Condom and scotch tape Finger cot and paraffin Rubber balloon-based Latex-based Rubber balloon Latex and paraffin Rubber balloon and cellophane Latex and fiberglass Rubber balloon, aluminum, and Latex, cellophane, and wax plastic foils Aluminum-based Cellophane-based Aluminum Cellophane and scotch tape Aluminum and plastic film Cellophane and wax Aluminum latex, cellophane, and Cellophane and latex paraffin Cellophane, aluminum foil, and latex Cellophane, carbon paper, and latex Cellophane, latex, and self-adhesive tape Cellophane, latex, and wax Miscellaneous Black electrician tape Scotch tape Scotch tape with outer condom Capsule Ampoule Nylon Plastic thimble Cigarette foil paper and cellophane Plastic surprise egg Packaging methods classification by packaging procedures Extemporary handmade Condom-based Finger cot-based Rubber balloon-based Cellophane and scotch tape Cellophane and latex Cellophane, latex, and selfadhesive tape Miscellaneous

Machine-manufactured made Latex-based Aluminum-based Cellophane and wax Cellophane, aluminum foil, and latex Cellophane, carbon paper, and latex Cellophane, latex, and wax

When more material was used, we described it from the inner to the outer layers.

through body packing or pushing, drugs in liquid form, as liquid cocaine and hashish oil, have always been transported using condoms131,152,173; this could be justified by the fact that condoms are easy to supply and fill with the previously mentioned liquid drugs. Information concerning the affiliation of body packers and pushers with major (or not) DTOs was also collected. We found that some types of packaging, such as the ones that need a machine-based manufacturing (eg, extreme compression of drug, vacuum-assisted arranging of layers), necessarily require an organized and expensive processing technique that only major DTOs can provide by buying dedicated machines.90,125,151,159,181 This could be useful to uncover whether drug couriers transport illicit substances obtained from major DTOs or, instead, minor DTOs, which can be linked to bigger ones. © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Systematic Review of Drug Packaging Methods

In particular, packages obtained from major DTOs always present a multilayer coverage of the drug with, in most cases, a paraffin or wax external coverage.64,71,79,105,127,160,181,188 The attempts to introduce new and different materials to reduce or alter the radiodensity of the packages are typical of major DTOs, which try to increase the number of false negatives at radiological examinations.100,122,181 This kind of information could be useful for police forces to retrace supply routes for materials and machineries used by DTOs, collect data, and link packaging methods features with specific DTOs.

Radiological Detectability and Packaging Methods It is well known that the improvements observed in packaging methods have been generally sought and achieved by DTOs with the aim to reduce the radiological detectability of the concealed drugs. For the first 25 years since the onset of the body packing phenomenon, clinicians used standard plain abdominal x-rays to detect packages. Currently, only few changes have been made in wrapping methods (ie, use of cellophane, aluminum, or carbon paper). This could be explained with the good results in terms of low detectability rates provided by the standard wrapping methods adjusted with the previously mentioned materials. The first revolution in packaging methods could be linked with the routine use, occurring from 1999, of computer tomography in examining suspected drug mules. As a consequence, DTOs started to wrap drugs in wax, paraffin, and fiberglass to reduce the detectability and increase false negatives. In a previous study,2 we analyzed the reasons of occurrence of false-negative radiological findings in body packing and pushing. These were mainly related to the following: (a) use of modern wrapping techniques, (b) ingestion of cannabis containing packages, (c) presence of a gasless abdomen, (d) scarce technical quality of the x-ray machines, (e) radiologists' lack of experience in interpreting x-ray films, or (f) lack of image sharpness caused by noncooperative body packers (eg, movement, spacing). In this field, the role played by sophisticated packaging techniques used in the attempt to reduce the radiodensity of the ingested drug packages is noteworthy. Nevertheless, the best result in terms of reduced detectability has not been provided by a new type of packaging material, but rather by the type of concealed drug. In particular, liquid cocaine has been demonstrated to be the most difficult drug to detect, even if transported by using simple condoms. This can be explained by the lower radiographic density of liquid cocaine and the higher adaptability of the packages to the intestinal anatomy, making them much less discernible from the feces in both x-rays and computer tomography examinations.2,131 A substantial failure for DTOs is represented by type 4 packages. These packages, even if at low risk of leakage and rupture, regularly shaped, with identical dimensions, and radiopaque, differ significantly from the usual appearance of the feces; therefore, they are easily identified through plain abdominal x-rays.2 In the attempt to solve this issue, DTOs started to incorporate aluminum foil, plastic food wrap, carbon paper, or other materials to reduce the radiodensity and minimize the risk of detection,50 increasing the number of false-negative imaging findings.175,203

CONCLUSIONS Besides the 5 packaging methods described over the years, our study suggests, for the first time, a standardized approach www.amjforensicmedicine.com


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for the description of drug packages based on the use of different materials and packaging procedures (handmade vs machinemanufactured), which provide a possible insight to the type of DTO involved. Details of the used packaging techniques are of considerable interest because they can be used to detect and ultimately fight drugs smuggling. Results obtained from our review permitted us to state that extemporary handmade packages obtained from condoms, balloons, or fingers of latex gloves (previously described as type I, II, and V) are more likely to swell, decay, or tear than machine-manufactured packages made of multiple layers (as packaging type III and IV), which are robust and likely to transit through the body intact. The main cause of the low resistance of type I, II, and V packages is due to the low quality of the wrapping technique that make these packages more susceptible to the corrosive action of the gastric secretions; indeed, as shown in Table 1, the stomach represent the organ where drug packages have been mostly found. Drug packages transported through body pushing have a very low risk of rupture, mainly because of the absence of corrosive secretions in the anatomical cavities used for it and to the absence of transit of such packages inside the body; the rupture of the drug package and the decease of the courier have been reported only in 1 case where an unusual and low-quality packaging has been used.192 In addition, extemporary made packages are more likely to be linked with body pushers and/or minor DTOs; on the contrary, major DTOs unlikely use this kind of methods (ie, concealing by hiding in body cavities and use of inadequate wrapping materials) when transporting drugs through different continents. The current refinement of packaging methods used by drug smuggling organizations not only decreases the risk of detection but also decreases the risk of package failure, with a low morbidity of drug couriers. Nevertheless, poisoning and other complications can still occur either in the country of origin,97 during the journey,66 or in the country of destination.74 The scientific community has given scarce attention to drug packaging analysis, focusing mainly on the toxicological and radiological features of body packing or pushing. Up to now, there has been limited thorough research about drug smuggling via internal drug concealment (body packing or pushing) and there have been few reports describing the details of the packaging methods adopted to facilitate the transportation and the nondetectability of smuggled drugs. In our opinion, these aspects must be considered essential topics for improving the knowledge and supporting criminal investigations. To conclude, we hope that this article may represent a useful tool to better comprehend body packing and pushing; collecting data concerning the materials and the techniques used for drugs smuggling could also help police forces retrace supply routes for materials and machineries necessary for production and distribution of drugs.

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