Don’t Tell Molly

What can public health do for those who don’t “Just Say No?”

Published on September 24, 2013by June H. Kim

Labor Day weekend, the final swan song of the summer, was not meant to be like this. At least for revelers at NYC’s Electric Zoo, summer ended not with a bang, but with a buck. The fifth installment of Made Event’s annual electronic dance music (EDM) festival was abruptly canceled after two attendees died of apparent overdoses. Within a week, news of similar deaths in Boston and Washington D.C. broke out, both involving 19-year-old females. All cases involved a purportedly purified form of ecstasy, otherwise known as Molly (from the chemical moniker MDMA).

While the ultimate goal of public health is to prevent this type of untimely death, the public health message of “Just Say No” may be avoiding the reality. After all, national trends in MDMA use show that some people will say “yes” regardless.

In these circumstances, public health experts find themselves in a precarious situation. Harm reduction messages targeted towards this group are rare in public health, as these messages almost inherently condone use. Consequently, inexperienced users are often left to rely on whatever peer advice they can garner before the effects kick in.

Unsurprisingly, this advice may not always be sound.

For the uninitiated, MDMA acts both as a stimulant and a psychedelic, an extremely pleasurable cocktail by itself and, for those who take it, an otherwise otherworldly experience at a rave. Often, MDMA users can find themselves dancing for hours on end without replacing lost fluids, placing themselves at grave risk of hyperthermic collapse. Accordingly, many users are counseled to stay hydrated: advice that has likely saved many lives.

However, it has also led to the perception that water consumption can reduce the toxicity of Molly. In reality, “water is an antidote to dancing, not an antidote to ecstasy”.

One other side effect of Molly is the release of an anti-diuretic hormone, which alerts the body to retain water (i.e. restricting urination). Combined with excessive water consumption, this “perfect storm” can severely dilute the salt content in the body, leading to a condition called hyponatremia. With severely depleted levels of salt, water rushes via osmotic pressure into cells, causing them to swell. In the skull-confined brain, the resulting compression can be lethal.

Early signs of hyponatremia include headaches, dizziness, nausea, and vomiting. Symptoms of advanced hyponatremia include hallucinations, bizarre or inappropriate behavior, impaired response, respiratory arrest, and seizures. This risk is particularly pronounced in females. Of cases involving ecstasy intoxication reported to the California Poison Control System from 2000 to 2005, females were at significantly increased odds of hyponatremia, coma, and death.

Despite being one of the most common causes of ecstasy-related death, hyponatremia remains underreported and relatively unknown outside of medical reports and Reddit boards. Nearly twenty years after the deaths of Leah Betts and Anna Wood, the dearth of public awareness surrounding this risk is perplexing.

While most would agree that heightened awareness of these complications is good, on the whole, very little has been done to dispense this information. Dissuading the use of MDMA while offering tips on how to reduce the risk of side effects is uncharted territory for public health.

After all, can a public health message espousing the dangers of MDMA co-exist with another that provides guidelines for safe practices? We’re left with two approaches that seem to offer conflicting messages—prohibition vs. harm reduction—and the perception that, at a certain point, harm reduction merely facilitates use.

But, we’ve heard it before.

Don’t binge drink, but if you must, don’t drive. Don’t shoot up, but if you must, use a clean needle. Could it follow: don’t pop Molly, but if you must, stay hydrated but don’t drink to excess?

There are those that will always have an appetite for certain diversions, no matter how much they are told to just say no. Faced with this conundrum, it’s not always clear what role public health can play in reducing death and disease while maintaining a consistent message. But, for those who may not respond to a public health “nanny,” harm reduction messages may be the next best thing.

Edited by Joshua Brooks