We thank Dr. Dufayet and colleagues for sharing their experience and improving literature on body-packers management [1]. Body-packing is a major public health issue in South America, and particularly in French Guiana where it has increased significantly in recent years [2]. Cocaine, mainly produced in Colombia, Venezuela, Peru and Bolivia, transits through the airports of Suriname and French Guiana to reach the European market. The Antinarcotic Office (OFAST) estimates that there are an average of 20 to 30 daily carriers on the Cayenne-Paris flight, and the French Observatory of Drugs and Drug addictions estimates that 15% of the cocaine consumed in France in recent years has been transported by body-packers from French Guiana [2]. According to the court of Cayenne, in the last 9 months, nearly 6000 ‘mules’ have been arrested at Cayenne airport (Unpublished data). Each year, 150 body-packers are managed in the hospital of Cayenne since 2015 [3,4]. This highly lucrative and flourishing market forced health professionals in French Guiana’s medical and emergency services to adapt their care management, with its risk of lethal evolution [3].

In our experience, the risk of death from massive cocaine intoxication is a major issue [5] but remains extremely rare during the management of these patients. The main complications we have been able to report in our 10 years of experience are mostly related to pellet stagnation in the digestive tract [3,4]. Over the years, the transportation of narcotics has evolved, and body-packing changed towards a micro-industrial manufacturing process, which is probably responsible for the reduced risk of breakage of these so-called ‘type 3’ pellets [6]. This observation has enabled teams of Cayenne General Hospital to adapt their management and integrate the use of laxatives (polyethylene glycol) as a standard of care, as well as endoscopy in case of pellet stagnation in the digestive tract [3,4]. As Dufayet et al. noticed, this approach is discussed in the literature [7,8], but up to now we have not recorded any complications associated with it. However, it seems important to remember that the majority of body-packers are probably not stopped. And to date, we are rarely confronted with cases of intoxication or death among these people who manage their exemption alone at home. Our observations thus encourage us to pursue our researches towards perspectives to reduce the intensity of management for patients at low risk of worsening, as it could be already the case in some countries [9]. In line with Dufayet’s observation, we have noted a recent evolution of body-packer profiles in French Guiana. Criminal networks are now recruiting more diverse profiles, frequently in precariousness and presenting more specific health problems: elderly, psychiatric antecedents or pregnancy. This observation should lead us to prefer a targeted management approach for these patients.

One more important point reported by Dr. Dufayet and colleagues is the medico-legal aspect. Although most patients are referred to the hospital by the police, some present spontaneously. In such circumstances, legislation varies from one country to another [1]. It is important to remember that, in France, healthcare professionals are bound by professional secrecy under article 226-13 of the penal code [10] but are also subject to article 434-1 of the penal code [11], which punishes failure to report a crime. However, the last paragraph of this article stipulates that professionals bound by secrecy cannot be penalized if they fail to make the required report and are therefore perfectly free to decide whether or not to do so.

Finally, in view of the increasing number of cases across the country, emergency physicians should indeed be familiar with the management of a body packer, but this has yet to be clarified by more studies on the subject. Emergency physicians need to be aware of the most frequent complication risks, that is, obstruction and digestive stagnation in case of micro-industrial pellets [12], but must also remain vigilant to the rarer risk of massive intoxication in case of pellets rupture of lesser quality [6,13].

Acknowledgements Conflicts of interest

There are no conflicts of interest.

References 1. Dufayet L, Deguette C, Vodovar D. Emergency medicine management of patients transporting cocaine by body-packing. Eur J Emerg Med 2023; 30:161–162. 2. Del Grande M, Cigolotti O, Prisse N, Karam A. MI Trafic de stupéfiants en provenance de Guyane: téléconférence. 2020. https://www.senat.fr/compte-rendu-commissions/20200525/mi_guyane.html. [Accessed 1 June 2023]. 3. Bonnefoy C, Nacher M, Egmann G, Pastre A, About V, Jeanbourquin D, et al. Epidemiology and medical management of body-packers in French Guiana between 2010 and 2015. J Am Coll Emerg Physicians Open 2022; 3:e12603. 4. Fremery A, Piriou V, Bonnefoy C, Hamiche K, Kallel H, Pujo J, et al. Description and evaluation of cocaine body-packers management in French Guiana (2016-2019). J Forensic Leg Med 2023; 95:102500. 5. Nelson L, Howland M, Lewin N, Smith S, Goldfrank L, Hoffman R. Goldfrank’s toxicologic emergencies. Eleventh ed. McGraw-Hill Education; 2019. 6. Cappelletti S, Piacentino D, Ciallella C. Systematic review of drug packaging methods in body packing and pushing: a need for a new classification. Am J Forensic Med Pathol 2019; 40:27–42. 7. Macedo G, Ribeiro T. Esophageal obstruction and endoscopic removal of a cocaine packet. Am J Gastroenterol 2001; 96:1656–1657. 8. Covarelli P, Burini G, Castellani E, Lombardo F, Caracappa D, Noya G, et al. Surgical treatment in drug body-packers. Am Surg 2014; 80:76–78. 9. Wirth C, Nickel CH, Stickel A, Mueller J, Fuchs S, Bingisser R. Outpatient management of individuals transporting drugs by body packing is feasible. Swiss Med Wkly 2019; 149:w20113. 11. Code pénal – Livre IV, Titre III, Chapitre IV, Section 1, Article 434-1. 2016. https://www.legifrance.gouv.fr/codes/article_lc/LEGIARTI000032207673. [Accessed 31 May 2023] 12. De Prost N, Lefebvre A, Questel F, Roche N. Prognosis of cocaine body-packers intensive care. Med 2005; 31:955–958. 13. Pujol-Cano N, Molina-Romero FX, Jimenez-Segovia M, Oseira-Reigosa A, Bonnin-Pascual J, Palma Zamora E, et al. Liquid cocaine body packing: a rare method for drug smuggling. Clin Toxicol 2021; 59:445–447.