The term “body packing” or “drug mule” refers to smuggling of illegal drugs (typically cocaine or heroin) by concealment in the GI tract in swallowed packages. Complications include packet rupture resulting in acute intoxication and bowel obstruction. We present a case of prolonged hospitalization due to opiate rupture, and highlight management strategies which may expedite packet expulsion in the setting of narcotic bowel. A 50-year-old Colombian female was admitted after being found acutely obtunded by her husband. He denied drug abuse, but reported she took medication for back pain. On arrival, the patient was tachycardic, bradypneic and hypoxemic to 55%. After urine toxicology exposed opiates, Naloxone infusion was started at 2mg/hour. Lab tests revealed: BUN 38, Cr 2.49, AST 383, ALT 428, INR 1.1, Lactate 5.22, WBC 19.7. Chest radiograph (CXR) showed pulmonary edema and aspiration pneumonia. Intubation was required on hospital day two for agitation with failed airway protection. Subsequent CXR revealed a “tic tac sign” of oblong structures in the stomach. Abdominal radiograph (AXR) confirmed dozens of similar structures suggestive of body packing. Four liters of polyethylene glycol were given daily over the next three days, complicated by hypernatremia to 153 mEq/L. Reglan and erythromycin were added, but packet transit halted in the colon. She was extubated on hospital day 9, finally passing 50 plus heroin packets under police supervision. Remaining packages in the rectum on AXR were successfully expulsed after fleet enema. Screening for drug packing in travelers with altered mental status with AXR and urine toxicology should be considered, though toxicology sensitivity is varied from 40-90%. For opiate ingestion, prompt continuous high dose Naloxone infusion in key. Data is still needed on the safety and efficacy of Methylnaltrexone here as a gut specific opiate antagonist. Polyethylene glycol can expedite GI transit, though should be limited to two doses to avoid electrolyte imbalances. Early extubation, oral diet and supervised ambulation may hasten bowel motility. Daily AXR is sufficient to follow progress, with CT thus limited to confirmation of post-evacuation clearance, and when there is concern for obstruction or perforation. While surgical treatment is typically advocated for foreign objects that fail to pass after 3-5 days, cases of opiate-induced ileus can be safely offered a longer conservative trial.1876_A Figure 1. Post intubation CXR showing bilateral interstitial edema, which can be associated with opiate overdose. Oval structures are identified in the stomach.1876_B Figure 2. Portable AXR showing the “Tic-Tac Sign” seen with body packing, marked by smooth and uniform oblong structures throughout the intestine.1876_C Figure 3. Abdominal and Pelvic CT scan on hospital day six demonstrating high-attenuation foreign bodies throughout the colon, without perforation.