Author: Dr. dr. Tri Maharani, MSi, SpEM(K), FICEP, FIMMA (Policy Analyst at the Ministry of Health's BKPK)
Nitrous oxide (N₂O), which is better known in the public space as gas tertawa or whippink, is not actually a prohibited substance. This substance is widely and legally used in medical services—particularly for anesthesia and sedation—and in the food industry as a whipped cream propellant. However, despite this legal status, the abuse of nitrous oxide through inhalation for recreational purposes is increasingly prevalent and presents a serious public health problem.
The practice of inhaling nitrous oxide for a brief euphoric sensation is often perceived as low-risk behavior. This perception is misleading. Clinically, nitrous oxide inhalation can cause acute hypoxia due to impaired oxygen supply. Under certain conditions, hypoxia can lead to sudden death. Repeated exposure is also known to inactivate vitamin B12, an essential substance for metabolism and nervous system function. The effects are severe: progressive neurological disorders, limb weakness, and even permanent disability.
Ironically, this health threat is developing in a regulatory gray area. Nitrous oxide is neither classified as a narcotic nor a psychotropic substance. As a result, its abuse falls outside the radar of addictive substance control policies. The government tends to intervene after the impact has occurred, rather than at the preventative stage. From a public health perspective, this approach is clearly inadequate.
The Face of Problems in Healthcare
In the field, the effects of this gas abuse are not always easily recognized. Patients often present to emergency departments with nonspecific complaints: shortness of breath, dizziness, decreased consciousness, or sensory and motor disturbances. They often end up in intensive care units with an unclear initial diagnosis. Without clinical vigilance, the connection between these symptoms and nitrous oxide exposure can be missed.
The long-term consequences deserve attention. Neurological disorders caused by vitamin B12 deficiency often occur in productive age groups, directly impacting quality of life, productivity, and the socioeconomic burden on families. More broadly, this condition contributes to increased healthcare costs and rehabilitation needs, which must be covered by the national health system.
Lagging Regulations
To date, nitrous oxide sales in Indonesia have been relatively free, with no quantity restrictions or verification mechanisms for intended use. These products also generally lack adequate warning labels regarding the dangers of inhalation. Furthermore, the national poisoning surveillance system does not specifically account for nitrous oxide exposure, so this issue tends to be overlooked in official data.
Legally, nitrous oxide holds a unique position in Indonesia. This substance is not classified as a narcotic or psychotropic substance. The National Narcotics Agency (BNN) categorizes it as a prescription drug intended only for medical and industrial purposes. In the food context, its use as a food additive—for example, in whipped cream products—is monitored by food authorities. In healthcare facilities, nitrous oxide is regulated as a medical gas through strict technical regulations to ensure safety and quality of service.
However, the lack of an explicit ban on recreational use creates a policy gap. While warnings about the dangers of laughing gas have been voiced by officials and the health community, warnings alone are insufficient when access to the substance remains widespread.
Learning from Neighboring Countries
Southeast Asian countries face similar situations, albeit with differing policy responses. Malaysia has placed nitrous oxide within its medical gas regulatory framework, focusing on registration and gas system standards. Singapore does not classify it as a narcotic, but authorities and healthcare professionals are actively responding to the rise in abuse through public warnings and contextual law enforcement. The Philippines has declared nitrous oxide a controlled substance but has issued official statements regarding its risks and illicit use. Thailand has taken an even stricter stance against recreational use, with health campaigns following a rise in clinical cases.
This comparison demonstrates that legal status does not necessarily equate to risk tolerance. The state can and should intervene through proportional, prevention-oriented regulation.
It's Time for a Preventive Approach
A repressive approach focused solely on prohibition is not the answer. What is needed is a public health-based preventative strategy. Nitrous oxide needs to be classified as a high-risk substance, even though it is not a narcotic, so that its sale and distribution can be regulated proportionately. Mandating clear health warning labels is a simple but important step to raise public awareness.
Furthermore, integrating nitrous oxide exposure into the national poisoning surveillance system would provide a more accurate picture of the extent of the problem. Coordinated education for the public and healthcare professionals is also essential for effective early detection and prevention.
In the long term, the establishment of a National Poison Center is a strategic necessity. This center can serve as a clinical reference and toxicology information center, while also strengthening the surveillance and rapid response system for various poisoning cases. Its existence will strengthen the state's capacity to protect the public from exposure to hazardous substances, including those legally distributed but abused.
The misuse of laughing gas is a stark example of how public health threats can thrive in a regulatory gray area. Addressing it requires the courage to shift from a reactive approach to preventative policies based on evidence and public health interests. Without such action, the risk of death, disability, and future burden on the healthcare system is only a matter of time.
