Singapore has made no secret of its “zero tolerance” stance on drugs and drug use. But how much do we actually know about this issue? What drives drug use and addiction? What resources are available in Singapore to help people recover and heal from addiction?
To start public learning and conversation, as well as to commemorate 2020’s Human Rights Day, the Transformative Justice Collective organised a webinar on 13 December on drug use, addiction, and policy in Singapore. The speakers were Ben (not his real name), a Singaporean recovering from addiction to drugs, Dr Munidasa Winslow, a specialist in addiction and impulse control disorders, and Prof Adeeba Kamarulzaman, an expert in infectious diseases, public health, and drug policy.
You can catch up on the session on YouTube here:
For those who would prefer to read instead of watching the video recording of the session, here’s a general round-up of comments made by all three speakers.
Ben described his own experiences of drug use and his resulting contact with the authorities.
Ben first started using drugs while working 14–15-hour days as a window washer. He was the main caregiver of his ill mother, and lived with her in a one-room rental flat. Many of his colleagues were using drugs to cope with the long hours, so he began using methamphetamines too. He said it gave him the energy to keep working.
In anticipation of settling down with his then-girlfriend, Ben decided to quit using drugs, but ran into difficulties. Under Singaporean law, doctors are required to report patients who use drugs to the Central Narcotics Bureau (CNB) within seven days. Ben had no criminal record at the time, and wished to avoid acquiring one. He was thus put off from seeking help at government hospitals. He tried seeking out private clinics where he might quietly get treatment without being reported, but they were too expensive. He was therefore left without support, and found it difficult to stop using drugs.
In 2018, he was admitted to hospital following a near-overdose. As feared, the hospital reported him to CNB and he ended up incarcerated in a Drug Rehabilitation Centre (DRC), a state-run rehabilitation facility. Ben described DRC as a “total prison setting”: he slept on the floor, food was served under the door, and residents were “packed” eight to a cell. Visits were permitted only twice a month. It was, as he said, “a tough time in my life”, experienced more as punishment than as care.
Ben also spent time in prison for drug consumption; he was imprisoned for six months, and upon his release had to serve another six months with electronic tagging, allowing the authorities to track his movements. The prison had found him work as a rider, a job that he described as difficult and stressful, with excessive work hours that led to fatigue.
Affected by this, Ben suffered a relapse. He called his case officer after this, hoping that he would be offered support. Instead, he said the case officer told him that he would be sent back to prison. Panicked, Ben broke his electronic tag. “I was scared and ran away,” he said. He was eventually caught and sent back to prison, with the added punishment of judicial caning.
Ben has since been released from prison, and is trying to put that experience behind him. “I’m cleared now,” he said of his present circumstances. “I’m a free man, I don’t owe the government anything.”
Ben expressed scepticism regarding the effectiveness of DRC and its programmes. He pointed out that the first-timers he’d spent time with in DRC have since returned to the rehabilitation centre again; some are even on their third stint in DRC. “I don’t think the programmes work,” he commented. “People keep coming back.”
Although classes and counselling were provided while he was in DRC, Ben felt that there hadn’t been enough guidance with exercising the skills these programmes sought to equip residents with. He said that many of these classes were conducted in the first three months of his time at DRC, after which he had to spend another three months in the centre. By the time of his release, it was difficult to connect what had been learnt with what he was encountering as he tried to reintegrate into life in the outside world.
Ben contrasted his experiences with what he’s since seen via Narcotics Anonymous (NA) support groups — since the pandemic restricted in-person gatherings, he’s been attending international NA meetings via Zoom. Through these meetings, Ben has been exposed to different approaches and settings for treatment and recovery from drug addiction. “It’s so beautiful to see people in other countries” attending Zoom meetings in recovery and treatment centres, he said, pointing out that mothers could even be with their children while undergoing treatment. “They are so lucky.”
As he shared, Ben also made a point to highlight another important issue affecting people struggling with addiction in Singapore: the fact that many insurance policies do not cover mental health, including drug and alcohol addiction. For instance, when he was warded for his near-overdose, he was told that his insurance did not cover the hospital bill. This, Ben said, can make it even more difficult for people without means to seek treatment and support.
He also noted that work-life balance was important, and an issue that intersects with that of poverty and class. As with his own experience, when one feels driven to work harder and for longer hours simply to make ends meet and provide for one’s family, one could be pushed to try out drugs as a way to deal with these circumstances. Therefore, a holistic approach to address drug use would also require paying attention to inequality and other circumstances faced by marginalised communities.
Dr Winslow’s experience
Dr Munidasa Winslow has worked with people grappling with addiction for a long time. In his presentation, he provided basic knowledge about what addiction is, and his experience of trying to provide support services in Singapore.
Stereotypical images of drug abuse and vice often come to mind when people think about addiction, but Dr Winslow prompted us to think more broadly as he shared the American Society of Addiction Medicine’s definition of addiction:
“Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences.”
As Dr Winslow pointed out, this definition doesn’t just cover the use of illicit drugs, but also other substances (such as legal prescription drugs or alcohol) and behavioural addictions (such as addiction to pornography or gambling).
In Singapore, opioids used to be the predominant drug of choice; today, things have shifted more towards methamphetamines and novel stimulants, for which treatment options are less developed. In Dr Winslow’s experience, many people who ended up with addiction to drugs began experimenting with their peers or colleagues; as with Ben’s experience, Dr Winslow said that he’d also heard from many meth users that they needed the drug to stay awake, so that they could work for longer.
No one sets out with the intention to become an addict. People instead begin using drugs, and then find over time that they’ve progressed to compulsive use, where they begin to move in social circles predominantly made up of other users, then to dysfunctional use, which presents grave problems in all aspects of their lives. Dr Winslow noted that, although the situation has improved compared to the statistics of the 1990s, both new and total users are on the rise in Singapore. About 50% of drug users are repeated offenders.
Dr Winslow talked about his early training in Australia, which he described as an “eye-opener” that demonstrated how much easier it is for doctors and therapists to treat people who are receiving treatment voluntarily (as opposed to being ordered to do so). Unlike Singapore (especially at the time when he was sent abroad), support services in Australia were available to addicts who had made their own decision to get well.
Back in Singapore, it took Dr Winslow time to persuade the authorities to provide services, especially since the matter was seen as one to be dealt with by CNB and the prison service. It was even a challenge to propose support group meetings, since there was a mindset among some of those in power that five addicts meeting up would amount to an “illegal assembly”. Pushing for more support to be made available required addressing and changing these attitudes.
Dr Winslow emphasised the importance of providing support services in the community; it was one thing to detox someone in hospital, but quite another for them to access services once out. In 2001, he and his colleagues succeeded in setting up the Community Addiction Management Service, learning “from scratch” what people in Singapore needed in recovery. In 2004, Dr Winslow was also involved in setting up We Care Community Services to provide another avenue for people to seek help with their addiction issues.
More opportunities to treat addictions opened up when he left for private practice in 2008, but Dr Winslow observed that the people he could help were limited to certain categories: people with employment, who could afford the fees charged by private practitioners, or expatriates, whose insurance policies covered mental health issues, unlike policies covering Singaporeans.
Much discussion about addiction in Singapore has focused on the individual, but it’s also possible to look at the issue through a more systemic and structural frame. One model Dr Winslow presented was dislocation theory, which looks at how a sense of dislocation within a society can push people towards addiction to substances or behaviours to cope with mental health issues and other stressors. This points to how socio-economic conditions can also have an impact on drug use and addiction; as Dr Winslow suggested, some use drugs to transport themselves away from the loneliness and isolation brought about by social and economic forces.
Still, Singapore tends to individualise the issue of drug use, perpetuating a narrative in which “drugs are bad and people who take them are bad”. Drug use is seen as evidence of “moral weakness” and a kind of “bad behaviour” to be punished out of the individual. For a long time, Singapore had an approach modelled on the “three strikes” laws in certain US states, sending people to jail the third time they are caught consuming drugs. Singapore retained this system even when those jurisdictions found that it didn’t work and replaced them with policies of managed care. It is only more recently that Singapore has begun taking steps away from this model — for example, the law was changed in 2019 so that third-time drug users can still be sent to DRC rather than prison. However, Singapore still allows punitive actions like judicial caning to be used on drug users.
Dr Winslow observed that, in the 1970s, then-Prime Minister Lee Kuan Yew saw drug addiction as a public order problem, instead of a matter of health and welfare. He noted that this dichotomy is a false one; it is possible to keep in mind the wider public good and care for the welfare of individuals. In fact, he argued that policies emphasising the welfare of individuals would be cheaper than incarcerating them.
In his experience, the Singapore government has been open to listening to expert advice, but have taken more progressive steps recently. But, unlike their approach to problem gambling, where multiple stakeholders were invited to the table to share their perspective, the government still tends to rely on their own internal experts when it comes to the matter of drugs.
Dr Winslow also reminded us not to get too hung up on reported recidivism rates, since these statistics are only concerned with the use of illicit drugs. Once someone moves off illicit drugs, they are considered a success story according to this tabulation — but that doesn’t mean that the underlying addictive behaviour has been addressed. Dr Winslow said that he’d seen patients who had moved from addiction to illegal drugs to legal ones such as prescription drugs, or developed behavioural addictions, which also have the potential of harming lives and relationships. If we really want to provide support and care for people in society, it’s necessary to also recognise and address the drivers of these addictions.
“You have to stop the primary addiction, but you also have to stop the other dysfunctional behaviours that come along with it. So there has to be programmes to address that,” he said.
Prof Adeeba’s research
Prof Adeeba made her opinion clear from the very beginning: drug addiction is a complex issue, made worse by imprisoning addicts. She said that many studies have shown that compulsory incarceration leads to higher rates of relapse than programmes which emphasise a community-based approach.
She also shared a Malaysian perspective, drawing on the situation in Singapore’s neighbour to demonstrate how criminalising drug use can lead to other problems. For example, in Malaysia, 60% of prison inmates have been jailed for drug-related crimes, leading to overcrowding in poorly ventilated prisons. Over this past year, the authorities have had to deal with COVID-19 outbreaks in these spaces where social distancing and mask-wearing hasn’t been feasible. This has given drug policy reformers an opening to convince the government to relook the practice of criminalising and jailing people for drug-related offences, and to point out the high financial and social costs of incarceration.
Prof Adeeba welcomed the United Nations’ move to reclassify cannabis and remove it from a list that had included it alongside more deadly and addictive opioids, like heroin — a move that the Singaporean government has expressed disagreement with. She also pointed out the importance of distinguishing between decriminalisation and legalisation, since people often wrongly conflate the two; just because one believes that a person shouldn’t be charged and jailed for drug use doesn’t mean that one supports the legalisation of drugs that have harmful effects. Instead of banning drug use, regulation could be more effective, as we already do with things like alcohol and cigarettes.
All three speakers observed that punitive policies that criminalise drug use also have the effect of framing users as “bad people”, which can affect one’s recovery journey.
“I came out and I had to shy away from my friends because people knew I went to prison,” Ben said. “I also got fired from my job because the employer found out I had a drug record which I did not declare. It affected me a lot mentally.”