Global crackdown on laughing gas as abuse rises; Singapore doctors see few cases

SINGAPORE: During a drug-fuelled Christmas party in Australia last year, Kevin was offered something he had not tried before – nitrous oxide, colloquially known as laughing gas.

In no time, the Singaporean found himself hooked. Over the next two months, he tried to achieve the same euphoric feeling by spending about A$500 (US$325) a week purely on laughing gas.

The daily habit took a major toll on Kevin’s health. He felt weak all the time and was constantly out of breath. He began eating less, causing him to lose weight and start skipping days at his construction job.

“You just keep hoping that high will come back,” the 31-year-old, who moved Down Under about three years ago, told CNA over the phone. He did not want his real name to be used.

“I was doing it for a few hours a day, just inhaling. I didn’t even want to inhale air. I just wanted to inhale nitrous oxide.”

It was only when he ran out of money and realised he was “slowly dying” that he quit cold turkey in March.

While Kevin was only recently introduced to nitrous oxide, its recreational use is by no means a new phenomenon.

The gas is typically sold in metal canisters and is commonly used as a dental and medical anaesthetic, as well as a motor fuel additive and even to make whipped cream. The euphoric effect it has on people gave rise to the term laughing gas.

Common side effects include dizziness, nausea, fatigue, loss of balance, mild hallucinations and excessive sweating. Inhaling the gas also runs the risk of asphyxiation or suffocation.

Long-term exposure can lead to a severe Vitamin B12 deficiency, which can in turn cause depression, memory loss, incontinence or spinal cord damage.

Over the past decade, it has become a relatively popular way to get a “legal high”, leading to more governments around the world – and in the Asia-Pacific region – clamping down on it.

"BROAD RANGE OF LEGITIMATE USES": MHA

In response to CNA's queries, Singapore authorities said nitrous oxide has not been outlawed here since it has various legitimate uses across various industries.

Nitrous oxide is not regulated under the Misuse of Drugs Act, which was amended in March to better tackle psychoactive substances, because it “falls under the category of substances which have a broad range of legitimate uses”, said the Ministry of Home Affairs.

It is currently listed as a permitted food additive in the Eighth Schedule of the Food Regulations, the ministry added.

A spokesperson from the Health Sciences Authority (HSA) said it regulates the gas only when it is used in a specific therapeutic product for treating a medical condition.

She added: “For such uses, the product is required to be registered with HSA to ensure that it meets the quality, safety, and efficacy standards before the product can be supplied for use by registered medical practitioners.”

OVERSEAS MOVES

The BBC reported in March that as part of a crackdown on anti-social behaviour, the UK government will criminalise the possession of laughing gas – the second most prevalent drug among young adults there aged 16 to 24 years, after cannabis. It is already illegal to produce, supply or import nitrous oxide for human consumption.

Last year, the European Union’s drugs agency warned that recreational use of the gas has been increasing among young people in Europe due to its wide availability, low price and perception that it is safe.

Closer to Singapore, Taiwan listed nitrous oxide as a controlled substance – the first non-toxic chemical under its Toxic Chemical Substances Control Act – in late 2020.

The Taipei Times reported that this came after the unregulated use of nitrous oxide for recreational purposes had risen in the past few months. The number of such cases in Taoyuan city jumped from 134 in 2019 to 455 in the first seven months of 2020.

Australia bans the supply of nitrous oxide for recreational purposes, but abusers like Kevin can easily turn to “smoke shops” or online delivery services to get their hands on canisters or even tanks of laughing gas.

Over the past decade, media reports have flagged locals and tourists in nearby countries like Vietnam, Thailand and Laos inhaling nitrous oxide using party balloons.

FEW CASES OF ADDICTION IN SINGAPORE

When CNA approached several doctors, addiction specialists and public and private hospitals in Singapore, most said they do not see many cases of nitrous oxide addiction, though they have treated a few patients who usually use it in tandem with other drugs.

They also cautioned that criminalising it could drive the trade underground, possibly leading to more abusing it for recreational purposes.

In 2017, the first reported case of laughing gas addiction in Singapore emerged in a psychiatry journal.

The Institute of Mental Health (IMH) had treated a 20-year-old Singaporean who escalated to using at least 100 cartridges, also known as whippets, of laughing gas daily. He began to lose control, develop cravings and become irritated if he did not use it.

At the time, the IMH doctors who treated him wrote that various factors, such as increasing use in the West and the fact that nitrous oxide is not illegal in Singapore, suggest more youths will experiment and possibly grow dependent on it.

Dr Bryan Ng, head and senior consultant of the National University Hospital's (NUH) anaesthesia department, told CNA that long-term exposure to nitrous oxide interferes with a person’s ability to break down Vitamin B12, which is needed for normal nerve function.

“These chronic abusers may develop numbness or weakness of their limbs or encounter sustained clumsiness. These deficits may improve if the abuse is stopped, but some may never fully recover,” he added.

As for how to treat Vitamin B12 deficiency, replacing the vitamin is key, while patients may also need rehabilitation if they have weak limbs or cognitive deficits due to nitrous oxide abuse. Their behaviour also needs to be addressed by a psychologist or psychiatrist, said Dr Kay Ng, a senior consultant at NUH’s neurology division.

Nevertheless, Dr Bryan Ng pointed out that because nitrous oxide is cleared from someone’s body “within minutes”, doctors do not usually see someone acutely intoxicated from the gas alone.

“But it may be taken along with other drugs, or the person may suffer from the side effects of nitrous oxide such as falling down when you're high on nitrous oxide, which can lead to hospital admission,” he said.

"GATEWAY DRUG"

Mr Andy Leach, director of addiction services at the Visions by Promises treatment centre, described nitrous oxide as a “gateway drug” that can lead to the abuse of more dangerous substances.

The psychotherapist said that in his personal view, criminalising reckless supply and the intent to supply it for recreational purposes should be the way to go, rather than making the possession of nitrous oxide an offence like how his native UK is looking to do.

The BBC had reported that in deciding this, the UK government went against recommendations from an advisory council.

Mr Leach pointed out: “Unfortunately, teenagers are going to experiment and the more you drive it underground, a lot of the time, it becomes more attractive."

Psychiatrist Sean David Vanniasingham, who also practises at Promises, said banning the use of laughing gas increases the risk of people not coming to professionals for help, given that most who use nitrous oxide have underlying disorders such as depression and anxiety.

Dr David said the majority of nitrous oxide cases he has seen throughout his career were among adolescents, who managed to get the gas from their peers.

Nevertheless, they acknowledged that severe dependence on nitrous oxide could result in devastating effects such as neurological damage.

One way to curb the problem is to educate people about addiction and its progression, said Mr Leach.

"Why do you feel the need to do nitrous on a daily basis? ... What's driving that? Because if you were happy with yourself, you wouldn't feel the need to change the way you feel," he added.

As for Kevin the abuser, kicking the habit proved to be the toughest part for him. He got his friends to accompany him for outdoor activities and "forced" himself to watch Netflix shows to take his mind off it.

"You just kill your brain cells and you can die from it ... The effect is really just for 10 seconds. It's really so stupid," he lamented.

"There's no point in trying it at all."