Illicit drug consumption in Singapore: Where are we in the fight against drugs?

Illicit drug consumption is associated with significant negative health, financial and social consequences. Yet, illicit drug consumption remains highly prevalent and continues to be a growing problem worldwide. In 2021, 1 in 17 people aged 15–64 in the world had used a drug in the past 12 months. Notwithstanding population growth, the estimated number of drug users grew from 240 million in 2011 to 296 million in 2021.¹

To our knowledge, as the first nationwide study to rigorously investigate the prevalence and correlates of illicit drug consumption in Singapore, Subramaniam et al. not only fill a critical gap in the local literature but also contribute to the discourse on substance use epidemiology and its implications for clinical practice, research and policy.²

The study’s findings reveal that the lifetime and past 12-month prevalence of illicit drug consumption in Singapore are 2.3% and 0.7%, respectively. Although these rates appear much lower than those reported in Western countries, they should not lull us into a false sense of security. It is crucial to note that the study’s community sample does not include institutionalised individuals, such as prison inmates among whom substance use disorders are exceedingly prevalent—in Singapore estimated at 60–70% of inmates.³ Furthermore, potential underreporting due to fear of legal repercussions in Singapore may underestimate prevalence. Nonetheless, these numbers alone are not negligible by any measure.

This study found that younger individuals aged 15–34 were at higher risk of lifetime consumption of drugs. The mean age of onset was 19.6 years, with 28.9% of those who endorsed lifetime drug consumption having done so before the age of 18. The identification of younger age as a risk factor for illicit drug consumption aligns with global trends.⁴ Youth mental health has been a focus in Singapore amid concerns of rising mental health issues and suicide.⁵ A complex interplay of individual, familial and community factors places youth at increased risk of drug abuse.⁶ Neurobiologically, the prefrontal cortex, responsible for decision-making and impulse control, is not fully developed until the mid-20s. Thus, youth are more susceptible to novelty-seeking and risk-taking behaviours, which include experimenting with illicit drugs.⁷ Peer influence is an important proximal risk factor in adolescent substance use, and youth are uniquely vulnerable to the effects of social media and digital communication, which tend to normalise and even glamourise substance misuse.⁸ Concurrently, the rapid proliferation of transnational e-commerce has made the barrier to drug procurement worryingly low, and detection impossibly daunting.⁹ Given that early substance use dramatically increases the risk of substance use disorder, targeted prevention strategies should focus on children before the sensitive adolescent period.¹⁰

The finding that current and ex-smokers, as well as those with hazardous alcohol use were at higher risk of drug consumption highlights the need to screen for illicit drug use and the use of multiple substances in individuals with substance use disorders. It also suggests that broader policies and efforts to discourage smoking and excessive alcohol consumption may reduce the risk of illicit drug use.

Notably, this study found that cannabis was the drug that was most first consumed (82.8%) and most frequently (68.0%) consumed across the lifetime. This finding stands in contrast to the 2023 annual statistics by Central Narcotics Bureau of Singapore showing cannabis coming in third (9% of total arrests), after methamphetamine (52%) and heroin (33%). This disparity is yet another reason this study is important—relying on arrest data alone may give us a skewed impression of actual prevalence. The legalisation and medicalisation of cannabis in many countries may contribute to lower perceived risk, which has been associated with a high risk of abusing cannabis in adolescents.¹¹ Consequently, targeted prevention and intervention strategies should focus on at-risk populations and debunking myths about the safety of recreational cannabis consumption.

The “stick” of zero tolerance approach as a nation has served as a strong deterrence. The mammoth task that lies ahead would be the “carrot” of education and treatment/rehabilitation. Repeated cannabis use during adolescence may result in long-lasting changes in brain function that can jeopardise educational, professional and social outcomes.¹² Yet, survey by the National Council Against Drug Abuse in 2020 found that the support among youths aged 18–30 for Singapore’s zero-tolerance approach against drugs was 82.5%, lower than the 88.3% for those above the age of 30.¹³ Perhaps more nuanced ground-up initiatives that engage youth and acknowledge their views and concerns need to be employed to gain their buy-in and formulate approaches to encourage abstinence from illicit drugs.

The observation of higher rates of anxiety disorders, chronic insomnia and depression among people who have used illicit drugs beckons a “chicken and egg” question. The Singapore Mental Health Study 2016 revealed that a significant proportion of individuals with mental health conditions do not seek help.¹⁴ While efforts to improve mental health literacy and access to care have likely reduced these figures, there remains a significant number of individuals with untreated anxiety disorders, depression and chronic insomnia who are reluctant to step forward. It is possible that some turn to illicit drugs to self-medicate, which perpetuates the underlying mental health problems, creating a vicious cycle.¹⁵ On the other hand, illicit drug use itself can be a contributor to mental health problems. Our national zero tolerance strategy relies on both supply interdiction and control, and demand reduction. This is often achieved by providing good assistance to substance users to completely stop their addictive urges and improve mental health such as those available at our National Addictions Management Service at the Institute of Mental Health. While Singapore has developed many support groups like 12-step Narcotics Anonymous groups, and therapy groups at the Singapore Anti-Narcotics Association, Singapore After-Care Association and WE CARE Community Services, it is important that medical professionals have the skills and knowledge to help identify, refer and treat persons who struggle with substance use disorders. This will significantly reduce demand in combination with our law enforcement policies.

Translating to on-the-ground measures, the study’s findings underscore the need for increased vigilance in screening for substance abuse. Part of Singapore’s National Mental Health and Well-being Strategy is to develop community mental health services, and it is imperative that measures are in place at these community-based services to perform timely screening for illicit drug use. This is especially crucial for people at risk, such as those who smoke and report hazardous alcohol use—both risk factors for lifetime illicit drug consumption.

This is a call for action to refine strategies that are already in place. The work of Subramaniam et al. highlights the need for targeted prevention and early intervention, particularly among youth, and suggests a place for screening measures in the community setting. At the population level, more can be done to address treatment gaps in mental health and addictive disorders. As we witness the devastating effects of illicit drug use in other countries, we must remain vigilant and adapt to face new challenges brought about by changing attitudes and advancements in technology.

Correspondence: Clin Asst Prof David Choon Liang Teo, Department of Psychological Medicine, Changi General Hospital, 2 Simei Street 3, Singapore 529889.
Email: [email protected]

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