To the Editor of the New England Journal of Medicine:
In their article discussing online drug information resources, Boyer et al. express concern over a comment made on Erowid.org that taking an SSRI after Ecstasy may reduce the risk of MDMA neurotoxicity.1 They state that taking an SSRI after MDMA might lead to serotonin syndrome, but their concern is unsubstantiated.
SSRI coadministration has been practiced by MDMA users for many years, without evidence of serotonin syndrome, as documented by published papers2 and dozens of unpublished reports collected by Erowid. Additionally, one clinical study administered 1.5 mg/kg MDMA (po) after citalopram with no evidence of increased medical risk (3). By blocking MDMA interactions with the serotonin transporter, SSRIs reduce the physiological and experiential effects of MDMA in humans2,3 and neurotoxicity in rodents.4 This includes attenuation of both heart rate and blood pressure increases.
No drug or drug combination is without risks. At least one adverse event (not involving serotonin syndrome) has been reported after this combination.5 Attempting to decrease risk of MDMA neurotoxicity with an SSRI may increase other risks, but serotonin syndrome is not known to be one of them.
The well meaning but misinformed concerns of Boyer et al. illustrate why many people rely on Erowid.org and other alternative information sources rather than biased "anti-drug" or government-sponsored sites. Unlike those sources, the Erowid.org archive maintains reliability through literature reviews, expert critiques, interviews with users and input from readers. We welcome comments and corrections.
1. Boyer EW, Shannon M, Hibberd PL. 2001. Web Sites with Misinformation about Illicit Drugs. N Engl J Med 345:469-471.
2. Stein DJ, Rink J. 1999. Effects of ‘Ecstasy' blocked by serotonin reuptake inhibitors. J Clin Psychiatry 60:485.
3. Liechti ME, Vollenweider FX. 2000. The serotonin uptake inhibitor citalopram reduces acute cardiovascular and vegetative effects of 3,4-methylenedioxymethamphetamine (‘Ecstasy') in healthy volunteers. J Psychopharmacol 14:269-74.
4. Shankaran M, Yamamoto BK, Gudelsky GA. 1999. Involvement of the serotonin transporter in the formation of hydroxyl radicals induced by 3,4-methylenedioxymethamphetamine. Eur J Pharmacol 385:103-10.
5. Lauerma H, Wuorela M, Halme M. 1998. Interaction of serotonin reuptake inhibitor and 3,4-methylenedioxymethamphetamine? Biol Psychiatry 43:929