It’s not often that the suggestion, “Drink more water” is a dangerous one, and yet that advice resulted in an upswing of MDMA-related deaths in the early 1990’s when the first harm reduction campaigns started urging club-goers to stay hydrated.
There is a risk of dehydration with MDMA, of course—there was something behind those campaigns, after all—but the relationship between MDMA and water isn’t as straightforward as once believed. It wasn’t until the mid-1990’s that the medical community and public began to understand that people dying while under the influence of MDMA weren’t dying of MDMA toxicity (a substance for which there is no known “death” dose) but from overhydration.
Why is your body more susceptible to over-hydration when on MDMA? Researchers are still unclear on the exact intricacies of how it works, but it seems to have something to do with MDMA’s influence on certain hormones and sodium levels in the bloodstream. While the details are yet to be fully understood, it’s clear that if we want a healthy future for MDMA-assisted therapy, harm reduction efforts, and practitioners, then we need to better understand MDMA’s complex relationship with water.
Risks of Dehydration and Overhydration
MDMA doesn’t directly dehydrate you. Instead, it raises your body temperature—especially important if you’re already in a hot club environment—which in turn causes you to sweat and lose fluids. If you don’t drink fluids and cool your body temperature, then you’re at risk of hyperthermia or heatstroke and, if you’re not replacing fluids, then you’ll likely become dehydrated as well.
So it’s true that the majority of MDMA-related hospitalizations are caused by heatstroke or dehydration, which is probably, in part, how the popular advice came about that drinking water could effectively “dilute” the strength of an ecstasy pill, much like how you would use water to sober up from drinking too much alcohol. But this kind of thinking can be dangerous because MDMA actually causes the body to retain water at the cellular level. And consuming overzealous amounts of water could land you in the hospital with a case of hyponatremia, a condition that occurs when the ratio of water and sodium in your blood is unbalanced.Hyponatremia historically happened as a result of kidney failure, liver disease, or extreme diarrhea, but these days, you’re most likely to hear it in one of the recent news stories about a death connected to MDMA.
So why do people using MDMA tend to drink more water than is healthy? While many report that MDMA just inherently makes them thirsty, it’s still debatable whether it actually causes polydipsia, the scientific term for an abnormally large thirst. It’s possible that the urge to drink simply comes from a want to cool down or because you’re getting dehydrated from drinking alcohol. With an increase in the number of deaths surrounding MDMA in recent years, product quality and concurrent drug use is a major concern for harm reduction efforts, but the high number of hyponatremia cases is enough to cause concern.
“A Severe Side Effect, Not a Rare Response”
Just how MDMA aggravates body conditions to the point of hyponatremia is a bit of a mystery, but researchers think it has something to do with its effect on the blood levels of sodium and certain water-regulating hormones.
Studies show that MDMA actually impairs the proper intake of water, causing a situation borne from osmosis in which your cells have dangerously low levels of sodium and, in turn, take on too much water. In a study published earlier this year, researchers performed two tests on participants—one in which MDMA alone was administered and another in which participants were required to drink a certain amount of water along with the MDMA. Participants had bloodwork done measuring sodium and osmosity, and it was shown that the combined effects of MDMA and drinking water were synergistic—they collectively decreased sodium to lower levels than their individual effects would have done.
Beyond MDMA’s effect on sodium levels, researchers also think that antidiuretic hormones—which limit urination used by the kidneys to manage the body’s water levels—play a part. Hyponatremia cases in MDMA users are usually a result of what’s called SIADH (Syndrome of Inappropriate Antidiuretic Hormone) in which your body releases high amounts of antidiuretic hormones. However, this most recent study showed that taking MDMA did not directly increase levels of antidiuretic hormones—which differs from the results of other studies. Though we cannot make any conclusive claims yet, it does appear that the relationship between MDMA, water, and AHD is more intricate than originally thought.
The results of the study published this year caused researchers to go so far as to say that hyponatremia represented “a severe form of a common drug effect rather than a rare idiosyncratic response.” This is particularly true for women, who have shown to be more sensitive to MDMA’s effects—both bad and good—than men.
Staying Safely Hydrated on MDMA
So then that still leaves the most important question—how much water should you drink if you take MDMA? To avoid risks of both hyperthermia and hyponatremia, the key is to stay hydrated while maintaining reasonable sodium levels. Drinking an electrolyte-boosting drink rather than water is generally agreed-upon to be a good choice. Not only will it guard you against overheating, but it will also protect you from dangerously low salt levels.
If you drink water, just how much you should drink depends on your body type and your environment, but 500 ml of water every hour is a good starting point. You also should keep tabs on how often you’re going to the bathroom, and be sure to urinate regularly, even if you don’t feel the urge. By being aware and keeping track of your water intake, you can avoid most of the risks of both dehydration and overhydration.
Beyond safe hydration, you should also always be aware of other risks with MDMA. While hyponatremia is a real threat, most MDMA-related deaths are caused by mixing MDMA with other substances (including alcohol) and poor-quality pills cut with other drugs. To help ensure the purity of your MDMA, harm reduction organizations like DanceSafe are sometimes available at festivals and raves to help test quality, and they can also offer other guidance on making your experience a healthy one. By using the available resources, being aware of your environment, and keeping your body properly hydrated, you can increase the likelihood of a safe, positive MDMA experience.