At most music festivals, nightclubs, and other settings with high MDMA use, there’s usually another drug being consumed: alcohol. Mixing alcohol and MDMA has become more popular over recent years, says Joseph J. Palamar, associate professor of population health at New York University Langone Medical Center. But when people wash down pills with cocktails, they may not realize this combination puts them at greater risk than either drug alone.
For one thing, both substances increase your risk for dehydration, says Tzvi Doron, a New York City-based physician and clinical director for the men’s health app Roman. MDMA does this by increasing your body temperature, muscle activity, and sweating, while alcohol makes you lose fluid by causing you to pee more. You’re at even greater risk for dehydration if you’re dancing in a crowd, as people often do at festivals and clubs.
When dehydration gets serious, you could experience neural compartment dehydration—a shortage of water available to your nerves, says James Giordano, professor of neurology and biochemistry at Georgetown University Medical Center. Fluid gets pulled out of your brain cells, compromising their ability to function, which could lead to heart failure, respiratory failure, or coma.
Alcohol’s diuretic properties—the ones that make you have to pee incessantly—also make it dangerous when combined with MDMA’s side effect of urinary retention. You’re producing more urine because of the alcohol, but because of the MDMA, you can’t get it out, which could lead to kidney or bladder damage and increased urea toxicity in the blood, Giordano says. In severe cases, urea toxicity could put you into a coma.
On top of that, the combined effects of alcohol and MDMA on the autonomic nervous system could lead to cardiac arrhythmia, or an abnormal heart rhythm that can disrupt your circulation, putting your organs at risk for damage, Giordano adds.
The two drugs combined can also be a double whammy for your judgment, Doron says. Since alcohol is a depressant, it impairs your motor abilities, which can make tasks like driving dangerous. But MDMA is a stimulant, which could make you feel alert and capable of performing such tasks even if you aren’t.
“Alcohol’s effects on judgement and coordination continue even when combined with MDMA,” Doron explains. “This can make for a particularly dangerous situation where people feel that they are less impaired than they actually are.” Drugs like MDMA can also lead you to misjudge how much alcohol you can tolerate and, increasing the chances that you’ll drink too much, Palamar says.
The consequences of combining alcohol and MDMA can outlast the drugs’ effects. Alcohol’s depressant properties can intensify the dreaded MDMA crash at the end of the night, where your serotonin supply wears off and you feel depressed, anxious, or irritable, Giordano tells me. And the next day, you could be dealing with two hangovers at once, as if the lethargy and crankiness of an MDMA hangover alone weren’t enough.
Many people have the false impression that alcohol isn’t a drug—or at least one they should be worrying about consuming—which can lead them to be thoughtless about what they mix it with. But alcohol interacts with recreational drugs just like any other substance. And the stronger the alcohol you’re consuming, the greater these unwanted effects will be, Giordano says: “The higher the proof, the higher the potency.” And, of course, the more of each drug you use, the greater every risk.
Obviously, both alcohol and MDMA carry risks even on their own. But if you’re going to use them, it’s safest to stick to one at a time. And whether you’re using both or just one, make sure to drink water to avoid dehydration.
Update: A previous version of this article stated that a person could be incapacitated due to neural compartment dehydration. The updated version reflects exactly what might happen if the person is incapacitated.
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